Advocating for Adolescent Reproductive Health in Sub-Saharan Africa[PDF]

Also available in French in [PDF] format.

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.