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Advocating for Adolescent Reproductive Health in Sub-Saharan Africa [PDF]
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Chapter 2. Laying
the
Foundation: Performing a Needs Assessment, Setting
Goals and Objectives
The Needs Assessment
A reproductive health
needs assessment examines the reproductive health status of a defined
group of people and analyzes factors that affect the reproductive health
of that population. It should provide clear, complete, and accurate
information on the health of young people in the target area, the services
available to them, and the policies affecting them. The needs assessment
provides a baseline from which to assess the impact of interventions,
helps identify the most effective programs and policies supporting
young people's reproductive health, and also determines where to focus
advocacy efforts.
A complete needs assessment
includes three components:
- Assessment
of the reproductive health status of young people in
a chosen community, region, or nation;
- Information
on the availability and utilization of reproductive health
information and services by young people, including gaps
and barriers; and
- Assessment
of local, regional, institutional, and national policies
that affect the availability and utilization of adolescent
reproductive health information and services.
It is not necessary
to collect all the information suggested above. Statistics
may be difficult to collect or may not exist. But, it is important
to accumulate enough data to describe the actual state of adolescent
health in the community. Accurate information will permit advocates
to design clear, achievable goals and objectives, and create an advocacy
campaign that meets the needs of the community.
Adolescent Reproductive
Health Indicators
The needs assessment
should profile the reproductive and sexual health status of a well-defined
target population. For example, an assessment may focus on all youth
ages 15 to 19 in a specific community, all students ages 13 to 19 attending
a specific school, or all street youth ages 15 to 19 in a defined urban
area.
It is helpful to collect
and compare local, regional, and national data to identify
local problems to address. While recent statistics provide
a "snapshot," noting
larger trends is also important, such as whether the rates
of pregnancy or STD infection are increasing or decreasing.
The following data may
be particularly useful:
- Percentage
of all adolescents who report sexual activity;
- Average
age at first intercourse;
- Average
age of menarche;
- Birth
rates among young women, both unmarried and married;
- STD rates
among youth;
- HIV and
AIDS cases among those 15 to 19 and 20 to 30 years old;
- Percentage
of sexually active youth using condoms and/or other contraceptives;
- Abortion
rates by age;
- Rates
of maternal morbidity and mortality due to unsafe abortion
and early childbirth;
- Average
age at marriage;
- Average
age at first birth;
- Percentage
of girls subjected to female genital mutilation (FGM)
and rates of morbidity and mortality resulting from the
practice;
- Infant
morbidity and mortality rates of children by age of mother;
- Rates
of alcohol and/or drug use connected with sexual activity
among youth;
- Incidence
of sexual abuse and violence;
- Prevalence
of prostitution among youth;
- Percentage
of youth reporting having "sugar daddies" or "sugar
mummies;"
- Percentage
of young people with stable sources of income;
- School
dropout rate and association with pregnancy, sexual harassment,
and school failure;
- Number
of out-of-school youth in the community;
- Number
of street- or street-involved youth in the community;
- Number
of youth orphaned as a result of the HIV/AIDS epidemic;
- Percentage
of youth enrolled in primary and secondary schools and
universities.
Assessing Information
and Services
A thorough assessment
of information and services currently available to young people in
the target area should be conducted as part of a needs assessment.
Information and/or services can come from schools, community-based
organizations, the government, religious organizations, health clinics,
chemists or pharmacies, and other programs or institutions which address
young people's reproductive health and development. The assessment
should attempt to determine which programs are working, which ones
youth actually use, which ones they do not use, and why.
Useful questions to
ask include:
- What
primary health care services exist in the community?
- What
reproductive health services exist? In particular, are
testing, counseling, and treatment for STDs and HIV available?
Are contraceptives and contraceptive counseling available?
- Are these
services available to young people?
- Are services "youth
friendly"? For example, do clinics offer convenient
hours and lower prices for young people? Has staff received
special training?
- Are reproductive
health services completely confidential?
- Are services
available to unmarried, as well as married, youth?
- What
services are not available?
- How many
young people use reproductive health services each month?
In six months? Each year?
- Is transportation
to services available?
- What
prevents teens from using existing services?
- Do schools
provide family life education that addresses sexuality,
reproductive health, and life skills? Do other organizations
provide such education? What subjects are covered?
- How are
young people traditionally educated about sexuality and
reproductive health?
- At what
age does school-based sexuality education begin?
- Do peer
education programs provide young people with reproductive
health information? Who are the peer educators' intended
audiences? What information do peer educators provide?
- Do some
groups of young people in the community receive reproductive
health information and services? Do some groups not receive
this information and services?
- Do national
or local media campaigns target youth directly with information
on reproductive health? What types of information do
they provide?
- What
other efforts exist to provide youth with reproductive
health information and services?
Policies That
Affect Adolescent Access to Services and Information
Finally, the needs assessment
should include an overview of policies that affect young people's reproductive
health. These policies may be of local or national origin and can either
protect or restrict young people's access to health care information
and services. Policies can also facilitate or obstruct the effectiveness
of NGOs which work with youth. Internal policies of institutions, such
as schools and clinics, also affect young people's access to accurate
information and services.
Policies may be written,
such as that life planning education is provided in schools, or unwritten,
such as that pregnant students should be expelled. Unwritten policies,
while more difficult to identify, may be crucial to young people's
well-being as they shape the behavior of decision makers.
Identifying all the
policies that affect young people's reproductive health is an important
part of the needs assessment as advocacy goals focus on improving existing
policies or proposing new policies where gaps exist. The following
questions will help identify local and national policies that affect
the health of young people:
- Do school
family life education curricula include realistic reproductive
health education and HIV/AIDS prevention education?
- Do schools
provide age-appropriate reproductive health information before most
young people initiate sexual activity?
- What
policies address girls' educational attainment?
- Do schools
provide additional training for school teachers who will
be teaching reproductive health topics?
- What
is the policy of schools toward students who become pregnant
or who impregnate another student?
- Do policies
prohibit the discussion of contraception, condom use,
or other important reproductive and sexual health issues
in schools?
- Do clinics
train their staff in adolescent health? What information
and skills training are provided to staff?
- Do clinic
policies restrict unmarried youth from obtaining information
and services?
- Do policies
restrict or ban FGM?
- What
is the minimum age of consent for marriage for girls?
For boys?
- Does
a statutory rape law exist? To what age does the law
apply?
- What
policies exist regarding teachers who have sexual relationships
with students?
- Which
national and local policies support or limit the efforts
of NGOs which work with young people?
- What
attitudes among parents, educators, traditional leaders,
and health providers affect the reproductive health needs
of youth? Do these beliefs reflect unwritten policies
among the community's leaders or cultural norms?
- Do local
businesses, factories, and companies educate young employees
about HIV/AIDS prevention? Do they encourage employees
to get information and services to prevent STDs and unintended
pregnancy?
- Do local
businesses work with other organizations in supporting
young people's reproductive health?
Obtaining the
Data
Finding funds or resources
to support a complete needs assessment can be difficult. For many NGOs,
assessing needs involves pulling together information from current
projects and outside sources, rather than undertaking new research.
Success may depend on the organization's collaboration with other individuals
and organizations committed to the well-being of youth. Working with
other organizations may bring additional expertise and information
to the needs assessment process. (See the chapter Building
Networks.)
Data for a needs assessment
can come from a variety of sources. The Ministry of Health is able
to provide information on national, regional and local health indicators.
Local sources, including other YSOs, may also have data. Research institutions,
universities, donors, and technical assistance organizations may be
willing to share health studies or demographic information. Hospitals,
family planning clinics, and YSOs may have statistics about the number
of adolescents who use their services and the incidence of sexually
transmitted diseases (STDs) or pregnancy rates among these youth. Peer
programs based in schools or community organizations can provide qualitative
and quantitative information about adolescent health.
Other Means
of Learning About Young People's Health
Statistics on young
people's reproductive and sexual health may be incomplete or difficult
to collect. When data is unavailable, surveys and focus groups can
provide information.
Surveys
Surveys can illustrate
young people's need for reproductive health services and information.
Whether information is collected through self-administered surveys
or interviews, respondents must be assured that their responses will
be kept confidential. Surveys can be conducted in cooperation with
YSOs or schools. At times, it may be wise to obtain the consent of
the headmaster and, sometimes, parents. Young people can also be surveyed
at town centers, markets, sports events, or other places where youth
congregate.
Surveying parents, government
officials, teachers, clinic staff, businesses, and the media will greatly
supplement information from the youth's survey. Adult survey results
can indicate the extent of community support for policies and programs
to meet young people's reproductive health needs. Surveys can also
identify community resistance on specific issues.
Focus Groups
Focus groups are structured
discussions on a specific issue or topic and led by a moderator. Focus
group members should have similar characteristics, such as age, sex,
and occupation. Focus group data should supplement other data collection
activities and should never be used as a sole source of information.
Focus groups provide qualitative information about how a specific audience
perceives a topic, program, or product. Focus group information can
help in developing an advocacy plan, assessing an advocacy campaign's
progress, and providing guidance for developing methods, instruments,
or tools to be used in larger, more formal evaluation efforts.
Forming Goals
and Objectives
Once the needs assessment
data are collected, advocates must identify and rank needs. Each need
should be assessed by creating a set of criteria.
Criteria for ranking
may include the following questions:
- How severe
is the problem? Is it life threatening? Does it cause
permanent disability?
- How frequently
does the problem occur? Do many young people experience
the problem? Do most experience it? Or is it rare?
- What
are the social or economic consequences of the problem?
What impact does it have on an individual, a family,
a community?
- Can advocacy
meaningfully affect the problem?
- Are resources
available to support the proposed actions?
- Given
existing resources, public attitudes, and current policies,
can advocates realistically have an effect on the problem?
Using these types of
criteria, advocates can select the one or two most pressing adolescent
reproductive and sexual health issues as their focus.
When the primary issues
are identified, advocates must then reformulate them as a goal. The
goal should be a broad statement of the advocacy effort's anticipated
accomplishments. The goal should also reflect the effort's long-term
vision. The goal should be attainable, but may not be measurable. For
example, the goal might be to improve adolescent reproductive health
by increasing access to reproductive health education and services.
An advocacy goal is
crucial because it shows how advocates plan to influence and produce
policies to improve adolescent reproductive health. The goal may help
advocates identify the kinds of policies that they should address,
such as:
- Increase
funds allocated for adolescent reproductive health programs;
- Change
laws or policies affecting young people's access to information
and services;
- Encourage
ministry support of, and collaboration with, youth-serving
organizations;
- Revise
internal policies of businesses and companies; and
- Identify
and change unwritten policies within communities, schools,
clinics, businesses, or other institutions.
Once a goal is agreed
upon, advocates should next formulate their objectives. Advocacy objectives
should be realistic, specific, and measurable in
charting progress toward the long-range goal. For
example, to reach the goal specified above, one advocacy
objective might be to "increase by 25 percent the funds allocated
by the Ministry of Health to adolescent reproductive programs
within five
years."
Objectives demonstrate
progress toward the desired changes in governmental or organizational
policies on adolescent reproductive and sexual health. Objectives should
have a clear time frame, be measurable, and realistically reflect the
capabilities of the advocacy effort. A time line will help advocates
visualize how the advocacy campaign is progressing and where it needs
to concentrate its efforts.
There are generally
three types of advocacy objectives: process, outcome, and impact.
Process objectives describe
the number or duration of specific advocacy activities. They are most
commonly tracked by using forms such as time lines, daily activity
logs, or field notes. A process objective for advocacy might be to
meet with five policy makers over the next six months to promote the
issues of concern. .
Outcome objectives identify
an advocacy effort's intermediate aims. These objectives generally
describe planned changes in knowledge, attitudes, or behaviors of those
targeted through advocacy efforts. For example, an outcome objective
might be to increase the number of parliamentarians voting for progressive
adolescent reproductive health policies by 40 percent within three
years. Another outcome objective might be for a local clinic to adopt
a policy within the next 12 months requiring medical staff to provide
contraceptives to young people who request them.
Impact objectives focus
on the advocacy effort's long-range effects on health status indicators.
An impact objective might be to increase adolescent use of contraceptives
in a given area by 20 percent within three years.
After developing the
objectives, advocates must agree upon the best strategies by which
to achieve them. If a number of organizations are working together
as a network or a coalition, this process will usually require open
discussion and debate as well as negotiation and compromise. While
network members might all agree that teen pregnancy is the primary
problem that they wish to address, differences in opinion may emerge
over how to address the problem. Some members may believe that the
network should work to affect policies regarding what young people
are taught in school, while others may be in favor of policies that
improve the services for youth at local clinics. Although differences
of opinion demand time and effort to resolve, they will contribute
to a better overall advocacy plan, in which every option has been considered.
Case
Study—The
Kenya Youth Initiatives Project (KYIP), Part 1
The Kenya Youth Initiatives
Project (KYIP) was implemented from April, 1994, through December,
1996, and was designed with the long-term goal of reducing unwanted
pregnancies and rates of STD infection among Kenyan youth. The project
was chaired by the National Council of Population and Development in
coordination with the Family Planning Association of Kenya (FPAK),
and was developed and implemented by a number of Kenyan YSOs. Johns
Hopkins University Population Communication Services provided technical
assistance and the United States Agency for International Development
(USAID) provided funding.
KYIP's advocacy component
was based on the findings of a Kenyan youth information, education,
and communication (IEC) needs assessment carried out by a team of representatives
from Kenya and U.S.-based NGOs, as well as a USAID representative.
The assessment found the policy environment in Kenya to be unfriendly
to youth and youth-serving programs, with numerous restrictive laws
preventing programs intended for youth from providing appropriate services
and education. The survey also identified the need for policy makers,
youth, and parents to have more accurate information about youth reproductive
health issues.
KYIP's advocacy sub-goals
included:
- Increasing
the knowledge of policy makers and community leaders
about the consequences of unwanted pregnancies, STDs,
and HIV/AIDS among Kenyan youth, and
- Encouraging
policy makers and community leaders to support and advocate
for appropriate sexuality education, counseling, and
services for youth.
Research
With the assistance
of the Centre for the Study of Adolescence (CSA), a Kenyan research
organization, KYIP undertook three research projects to help determine
appropriate advocacy strategies and messages for opinion leaders and
the public.
KYIP began by analyzing
the content and nature of media articles reporting on adolescent reproductive
health issues, looking for topics such as rape, female circumcision,
early marriage, pregnancy, school dropout, family life education, and
STDs. KYIP found that issues related to morality received more media
coverage when youth were involved, and that the media played an important
role in generating public alarm about adolescent reproductive health
issues.
The second study examined
the national legislative policy environment for adolescent
reproductive health by reviewing existing laws, policies,
and sessional papers.
KYIP discovered that policies on adolescent access to reproductive
health services were based on laws written to address either
children specifically or the population in general. Existing
laws about reproductive
health were vague, misleading, and contradictory and included
no adequate definition of "youth." Family life education
in primary and secondary schools was not comprehensive
and did not address sexuality
and reproductive health. As a rule, the Kenyan government
was reluctant to make reproductive health information available
to youth. Adolescents
receiving reproductive health services were required to
obtain parental consent.
As the third part of
the study, CSA conducted in-depth interviews with 100 national, local,
and community policy makers and opinion leaders to understand their
feelings and beliefs about adolescent reproductive health. Respondents
identified the top problems affecting youth in Kenya today as: unemployment
(21 percent); reproductive health problems (21 percent); drug abuse
(20 percent); and idleness (18 percent). Respondents believed Kenyan
youth engage in sexual activity because of 1) financial problems (21
percent); 2) lack of sexuality information because of a breakdown in
tradition around families providing this education (19 percent); 3)
parents' reluctance to talk to their children about morals and values
(19 percent); and 4) idleness (15 percent). Policy makers noted several
issues, including reproductive health, that were related to adolescent
well-being and development; but few felt that policy makers should
make a priority of reproductive health for adolescents.
When asked what changes
they believed were necessary to address adolescent reproductive health
problems, policy makers and leaders cited both a need for information
to be more available to youth and their parents and also a need for
training of health care providers in adolescent counseling. They also
recommended holding forums to educate parents about adolescent health
as well as giving supporters and opponents of school family life education
an opportunity to discuss their differences and find common ground.
Developing an
Advocacy Strategy
Based on the research,
KYIP concluded that individual leaders supported the provision of reproductive
health services to youth, but that most were reluctant to raise the
issue because they feared a negative public reaction. KYIP decided
to make adolescent reproductive health a topic for public debate, believing
that policy makers would be more comfortable discussing adolescent
reproductive health once it was demonstrated to be a serious concern
of Kenyans.
KYIP's strategy was
to present information about adolescent reproductive health to policy
makers in a new and interesting manner. KYIP used workshops to develop
compelling messages and interesting materials that would encourage
leaders to take action to improve reproductive health services for
youth. KYIP developed three key messages for leaders:
- Invest
in preventive health services because most young people's
reproductive health problems are preventable.
- The consequences
of sexual activity can be costly to youth.
- Leaders
have a responsibility to foster and support improved
reproductive health services for youth.
KYIP also recommended
three key actions that leaders could take to address the identified
problems:
- Speak
out in favor of programs that provide services, information,
and counseling to youth.
- Support
legislation and policies which facilitate young people's
access to reproductive health information, counseling,
and services.
- Encourage
other leaders in the community, such as religious leaders,
teachers, health care providers, and the media, to discuss
youth issues.
KYIP provided leaders
with written materials that permitted them to speak confidently and
factually about adolescent reproductive health issues. KYIP's strategy
packets included fact sheets with statistics about adolescent reproductive
health in Kenya, a booklet called Supporting Kenyan Youth: A Leader's
Guide to Action, and a poster condensing some of the most crucial
information from the fact sheets. Packets were distributed to local
and national leaders, the media, and health care professionals.
Training Youth
Advocates
Communities throughout
Kenya nominated people to participate in a two-week training workshop
to become youth advocates. The advocates included religious leaders,
health care workers, and people already committed to youth issues in
their communities. The advocates, determined to raise local awareness
of adolescent reproductive health, received training in advocacy skills
and current adolescent reproductive health problems. Young people also
participated in the training workshop to give the adult participants
a youthful perspective on adolescent reproductive health issues.
Participants returned
to their communities to serve as resources in adolescent reproductive
health and to create a dialogue between existing community groups and
District Development Committees. The youth advocates' mandates were
to raise awareness of youth issues in the community, educate leaders
about adolescent reproductive health, and encourage local leaders to
take actions to improve adolescent reproductive health in their communities.
Having local leaders bring information about adolescent reproductive
health into their communities empowered community members to take action.
Communities that were sensitized to adolescent reproductive health
needs placed pressure on the legislators representing them on a national
level.
Results and
Lessons Learned
An evaluation completed
by the youth advocates at a follow-up workshop showed that they were
pleased with the KYIP materials, wanted more information, and desired
to be more involved in youth issues in their communities. KYIP's evaluation
showed that youth advocates increased public awareness of adolescent
health issues and contributed to the growing debate on the provision
of adolescent reproductive health information and services in Kenya.
As a result, legislators who had been hesitant to voice their concerns
about adolescent reproductive health may have become more vocal, knowing
that they had the encouragement and support of their constituents.
Some lessons learned
follow:
- Leaders
are parents first. Resolving adolescent reproductive
health problems, therefore, is important to them both
as parents and as leaders, making them obvious targets
for a number of different advocacy messages.
- Messages
that are personal and compelling are most effective.
Obtain broad consensus
among as many groups and leaders as possible. Over time, advocacy messages
can become more specific, as leaders become sensitized to adolescent
reproductive health needs.
Source/Citation:
Shannon A. Advocating for Adolescent Reproductive Health in Sub-Saharan Africa. Washington, DC: Advocates for Youth, 1998.
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