This episode, we continue our focus on youth—but this time, we will focus on service delivery. We will hear about three distinct healthcare settings—in Kenya, Mexico, and Zimbabwe—that respond to the specific needs of adolescents and youth and ensure that they have access to the family planning and reproductive health care that meets their unique needs.
www.knowledgesuccess.org/inside-the-fp-story
From Knowledge SUCCESS and the World Health Organization’s IBP Network, this is Season 2 of Inside the FP Story—a podcast with family planning professionals, for family planning professionals.
The international family planning field has generated a lot of data, a lot of reports, and a lot of lessons learned. But we don’t often have the opportunity to get behind that information, to hear directly from the people who implemented a program, or who did the analysis, and so we reinvent the wheel or miss the mark because we don’t know what could be really critical in a particular context. Inside the FP Story is that opportunity.
Each season, we hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, the Partnerships Team Lead for the Knowledge SUCCESS project. I’m pleased to welcome our narrator, Sakshi Sharma.
Narrator In Season 2 of “Inside the FP Story,” Knowledge SUCCESS is collaborating with the IBP Network to explore issues around implementing family planning programs. During this six episode season, you will hear from the authors of a series of implementation stories—published by the IBP Network and Knowledge SUCCESS. These stories offer practical examples—and specific guidance for others—on implementing high-impact practices in family planning and using the latest tools and guidance from the World Health Organization, or WHO.
Last episode, we heard about three community programs that reach diverse groups of adolescents with reproductive health information—groups of girls making jewelry in Benin, high school students in Ecuador, and young people with disabilities in Colombia. This episode, we continue our focus on youth—but this time, we focus on service delivery. We will hear about three distinct healthcare settings—in Kenya, Mexico, and Zimbabwe—that respond to the specific needs of adolescents and youth and ensure that they have access to the family planning and reproductive health care that meets their unique needs.
Our first story is about the “After Hours Adolescent Project”—or AHAP for short. The University of California Fielding school of Public Health, in partnership with the Center for the Study of Adolescence and the Kenya Ministry of Health, implemented AHAP in rural western Kenya. Public health facilities extended their clinic hours into evenings and weekends to accommodate adolescents’ schedules, and trained nurses to provide comprehensive sexuality education in nearby schools, which followed international standards.
We spoke with Paula Tavrow from the University of California, Los Angeles, about this program.
Paula Tavrow My name is Paula Tavrow, and I'm an Adjunct Professor in the Department of Community Health Sciences at the Fielding School of Public Health at the University of California in Los Angeles. And for a number of years, I have collaborated with the Center for the Study of Adolescence, which is based in Nairobi, Kenya. And we have done several projects together.
Narrator AHAP took place in Bungoma County in Western Kenya, a county of about one and a half million people.
Paula Tavrow The project was a randomized controlled trial. It involved government health facilities, health centers, and dispensaries in rural parts of Bungoma County. And so we requested or we asked facilities if they would like to participate, and we received 13 interested facilities. So what we did was we took those 13 and then we randomized them into three categories. One was to receive AHAP, the entire program. The second was a smaller version, which I will go into in a moment. And the third was the control.
Narrator The program used guidance from the “Adolescent-Friendly Contraceptive Services” high-impact practice brief—for example, to improve the competency of service providers to address the specific needs of adolescents, and to employ a variety of channels and sectors (like schools) to reach adolescents.
In the AHAP program, newly graduated nurses participated in a three-day training on SRH knowledge, skills, and values clarification—based on the WHO’s quality assessment guide. They also received a five-day training in comprehensive sexuality education.
Paula Tavrow For the full model, what these nurses did is that they worked part-time in the facility and they worked part time in the community giving CSE talks in schools and in community settings and so on.
And another innovation of the project was that we worked with each facility that was participating to see how late they could stay open so that students would be able to go to a facility without worrying about whether they'd be seen by their parents or be seen by other members of the community, or that they'd have to miss school or miss work or something of that nature.
So, the facilities are normally closed at 4:00 PM or, or in some cases, 5:00 PM. And we were able to convince them to stay open till at least 6:30, and some stayed open till 7:30. Now only 77% of these facilities actually had lighting. So we also did have to bring in some very basic lighting for some facilities, so they could be open after hours.
So five of the facilities had the facility open later, after hours. The nurse also did some work in the community or did some of this education in the community, and they also opened for a few hours on one day of the weekend, usually Saturday.
The other facilities, the nurse did not do CSE in the community, but he or she did stay at the facility after hours. So in other words, they would arrive, say around 11 or noon and they would stay till around 7 or 8 PM. They also had new registers to use after hours and they had supplies available to them after hours so that they could provide the full range of sexual and reproductive health services.
Narrator Meanwhile, control facilities did not change their hours or programming.
During a one year implementation period, the number of adolescent visits to the AHAP health facilities increased dramatically.
Paula Tavrow So what we found after only one year of this program was that the number of SRHR visits overall went up by 87% in the AHAP facilities, as compared to no change in the control facilities. And in particular, where the nurse also did some of this sexuality education in the community, the visits nearly doubled. So they went to 97% increase in just one year's time, versus a 77% in the program where the nurse did not go into the community.
Narrator We asked how they were able to get the public facilities to participate in the program.
Paula Tavrow Well, it wasn't very difficult to get the public facilities to agree to extend their hours, because in some cases the nurses lived very close by, or even on the premises or in that sort of campus of the facility. And the facilities also recognized that it was difficult for young people who are shy and who are afraid of their confidentiality being violated or want a very private experience. So, they were aware that this was a problem. And so they were willing to participate in this also because it benefited them to get an additional nurse who could also perform other functions during the ordinary working hours, even delivering babies and the like.
Narrator Another strategy the program used was reaching out to recent secondary school graduates to train them in comprehensive sexuality education—or CSE. The program referred to these recent graduates as “rovers.” Through adult-youth partnership, rovers worked closely with the nurses, supporting and assisting them with CSE activities.
Paula Tavrow We paid them just a minimal stipend and trained them in CSE. And they were able to go to different schools, into the community, and they talked to the administrators and also to local leaders. And so they were able to set up opportunities for them, this AHAP nurse, just to show up and give CSE talks. So in other words, the rover handled all the logistics and it made it then very easy for the nurse just to come and do the CSE.
Narrator In order for this program to be implemented to scale, government buy-in is essential. This would help ensure that nurses’ salaries are paid, and that other changes are made to the facilities, similar to what the program did—including improved lighting, and ensuring the availability of health commodities.
Paula Tavrow So for scale-up it would be vital that the commodities would be in place, that the nurses would be trained, there would be a commitment to sustain, and that there would be, I think, some discussion of ministry of education and ministry of health, of the mutual benefit of this program so that the schools would be welcoming of these nurses to come in and do CSE. So in general, schools did see the value of having a nurse come in, and teachers also welcomed that because they felt the nurse was better equipped to handle sensitive questions that might arise and was comfortable with these kinds of topics.
Narrator To ensure method choice, the program offered a wide range of contraceptive methods, including long-acting methods like implants. In addition to products, counseling on SRH behavior was also included.
Paula said the program helped empower young people—not only were they getting reproductive health information in schools, but they got to know the nurses by name.
Paula Tavrow So they could show up and say, I would like to speak with Rachel. And it was very empowering. And if Rachel, the AHAP nurse, say, was not there that young person would often leave. They only wanted to speak with the person that they had seen, who they knew would not humiliate them, was friendly, and would want to assist them. So I think that that was the essence of this project and why it worked was because these young nurses who had now been trained in how to talk to these people, who had also been in the community, then they had this sort of rapport, or they broke down barriers.
Narrator By training providers and addressing harmful misconceptions and stereotypes, this program has helped create experiences that are welcoming and friendly to adolescents.
Also, because the nurses were active in the community, they helped increase adolescents’ comfort level with SRH services. Privacy and trust are very important to young people, and providing CSE in the community helped adolescents talk openly about SRH and make sound decisions.
We asked Paula what she wished she’d known before the project began.
Paula Tavrow I think that the thing that I didn't appreciate is that it's so essential that the Ministry of Health agreed to keep these people on board at the end of the project, that was the main drawback is that once they were fully trained, ready to go, the community enjoyed working with them. So there's just a lot of goodwill. But then at the end of the project period, these nurses were just let go. And even though the facilities often did enjoy having them, there hadn't been a priority. There wasn't money set aside to keep them employed. And so that's where I think more negotiation has to occur from the beginning to make sure that they aren't just let go as soon as the project is over.
Narrator Another challenge the program faced was community members wondering what was going on at these facilities after hours, and why young people were there.
Paula Tavrow And, and they, questioned it and they were concerned. So we had several community meetings that were organized by the rovers so that they would be educated about what was going on and they could raise any concerns. And afterwards, people really got it and they seem to find it very acceptable. So that worked very well to have some community meetings to discuss it. We had had some stakeholder conversations prior to the launch, but then later we recognized the need for some of these community meetings.
Narrator Securing adequate commodities was another challenge for the project—from contraceptives to pregnancy test kits, to STI drugs.
Finally, the program faced bias on the part of providers, as well as the need for increased health worker capacity in SRH.
Paula Tavrow Since these nurses were newly graduated, we actually didn't expect there to be that level, they had a very high level of myths that they still believed in, even though they just completed nursing school. So for instance, about half thought that contraceptive use could render a girl infertile. Nearly two-thirds thought that if a young person came to a facility, they would have to bring their parents in order to get contraceptive services if they were under age. And these are not true. And so we were a little surprised that they had all these misconceptions, but by spending three days working through them, discussing them, and challenging some of those and giving examples and so on, they really learned. And a year later when we came back and did the evaluation virtually none of these myths were any longer believed in.
Narrator When we asked Paula what advice she would give to those implementing similar programs, she encouraged others to empathize with young people.
Paula Tavrow I think that what's important is for people to get into the view of the young client. In other words, try to walk in their shoes. And look at all the challenges for young people, particularly in rural areas where everyone knows your business and so on, how many barriers there really are for young people to get contraceptive and STI and pregnancy test services. So that's why many of them actually avoid the health services altogether and might go to, say, a pharmacy if they can afford it. But remember very few of these young people can afford much. They're very poor in general. They don't have any regular income. So it's very important that the public health services be accessible to them. And by being accessible, that they are offering services at times that are convenient to them in a way that these young people are not feeling ashamed, with people who really are interested in explaining things to them and working with them.
Narrator The After Hours Adolescent Project shows us the importance of meeting adolescents where they are, and ensuring high-quality FP/RH clinical pre- and in-service education for providers. Offering services that are truly accessible and responsive to the needs of adolescents helps ensure that they can prevent unintended pregnancies and sexually transmitted infections.
Our next story also highlights the importance of providing adolescent-responsive services—this time, in the pharmacy setting in Mexico, where certain methods of contraception—including oral contraceptive pills and condoms—are available over the counter. As in many other countries around the world, adolescents often obtain contraception from pharmacies, which have many benefits for young people. Pharmacies have extended hours, the transactions involve little time investment, and anonymity and confidentiality are preserved. However, staff are not always trained to give proper information about family planning.
The Mexican Foundation for Family Planning—known as MexFam—implemented with support from the Packard Foundation, Population Council, Pfizer Mexico, and the International Planned Parenthood Federation to train pharmacists to improve access to contraceptives among adolescents. Those who complete the training are accredited as a “Solidarity Pharmacy.”
We spoke to Lorena Santos of MexFam about this program.
Lorena Santos I am Lorena Santos. I work for the Mexican Foundation for Family Planning, known as MexFam. My role in the foundation is Research Manager.
The high-impact strategy developed by Mex Fam focused on strengthening the capacity of people who serve at the counter in a pharmacy—whether it is a small pharmacy or a pharmacy that belongs to these large pharmaceutical chains—to provide first-hand guidance to adolescents and young people who are already their customers.
Pharmacies already exist in each of the communities in our country, so they are a point of service that provides contraceptives at a determined cost. However, it is often viewed as outside of the promotion of sexual and reproductive health. So what we seek to highlight is the role of pharmacies in promotion and education in the sexual and reproductive health of adolescents and also of adults.
Narrator Pharmacies are the main point of access to pills and condoms for eight out of ten young people in Mexico; however, pharmacists’ information on the correct use of contraceptives is often insufficient. With this in mind, MexFam designed the “Solidarity Pharmacy” program, in which a team of promoters, referred to as the “brigade team,” goes out into the communities and uses a mapping technique to identify the pharmacies and note the hours they are open. They then promote the program among the pharmacists.
Lorena Santos The main incentive is, first, to learn about the problems that we are bringing to them, specifically the problem of young people not accessing contraception, which is a problem that makes a lot of sense to the pharmacists. And another incentive is updating their practical knowledge and clarifying any questions—and addressing biases. This is the technical portion provided by the MexFam team, along with materials that, depending on our available resources, are donated to them.
Along the way, the pharmacist realizes that they can do more than just sell over the counter, but also promote the well-being of young people.
Narrator Working with MexFam is a strong incentive for pharmacists. MexFam has existed for 55 years and they have a reputation for doing positive work throughout the country. And within communities, they have a broad network of volunteers of all ages working to promote MexFam’s mission.
Over the course of the program, they have reached large numbers of people—in terms of increased sales and increased knowledge regarding contraception among young people. But beyond that, the impact of the program is also apparent in the behaviors and beliefs among pharmacists themselves, when it comes to family planning.
We asked Lorena to describe what problems the program encountered.
Lorena Santos Yes, well, the first challenge is the pharmacist's time available. We may offer a session to discuss emergency contraception, and the session is scheduled to last one to two hours. The pharmacist doesn't have one or two continuous hours, but they do have a lot of downtime between customers. They don't control the agenda of customers who are going to buy from them, so then you have to adapt your strategy.
Narrator Since pharmacists cannot always predict when they will be available, the program had to be flexible—for example, the brigade team would pause their sessions when the pharmacist had customers.
We asked Lorena what she hopes others can learn from her experience, and she talked about the importance of public-private collaboration.
Lorena Santos This is an invitation to all the actors in the private and public sectors to invest in this type of practice. We need to improve the promotion from the community pharmacy to these friendly services that exist in the private centers, in the health units of our countries or our communities, so that they are recognized more as allies in this health promotion and not as competitors.
Narrator One theme throughout all the adolescent and youth stories we are featuring this episode, as well as last episode, is truly involving youth in programming that affects their reproductive health. This program is no different.
Lorena Santos It is important that every program, project and practice considers the specific needs of adolescents so that the programs are really adapted and really respond to their meanings, to their beliefs, to their doubts, to those needs that they have and not to the needs of the adult world that the adult world thinks that adolescents have. So, if we really want to improve access to contraception and reduce teenage pregnancy rates, teenagers are the ones who give us the guidelines to improve the programs and adapt the strategies and interventions and even how we should deliver the messages so that these messages, these services are really meaningful to them and they really ask for them, demand them more and these needs they have can be solved.
Narrator This program centered adolescents in the design, implementation, and evaluation. And this strategy was key to the program’s success. By involving young people directly, they were able to overcome biases related to adolescents’ behavior and use of family planning.
Lorena Santos The participation of the adolescents themselves as educators was a key strategy. The work of youth promoters helped eliminate the prejudices that providers have in relation to the adolescent, not as an actor who knows, but as an actor who educates, as an actor who informs and guides the practice of an adult service provider, in this case pharmacists.
So I believe that this was a great success of the intervention and that the interaction with the adolescent itself breaks down these prejudices. In relation to the prejudices that the service provider has regarding the sexuality and reproductive aspects of adolescents and young people, listening to the language and the very natural and spontaneous expression of adolescents with truthful and evidence-based information was another element that made it possible, during the interaction and dialogue at the counter, to overcome all these prejudices that adults have.
Narrator Once they complete the program, a pharmacy is accredited as a “Solidarity Pharmacy.” They are provided with a poster to display, so young people can easily identify them as a safe space to access contraceptive services. Pharmacists also receive various brochures—including those with correct use of each of the contraceptives and access routes to health center services.
Through the “Solidarity Pharmacies,” MexFam was able to create spaces where adolescents could freely obtain contraception—and the program is working to break down barriers and conquer social norms that can prevent adolescents from accessing the services they need.
Narrator Our final story this episode will explore another innovative approach for improving access to family planning and other reproductive health services among adolescents.
In Zimbabwe, the Ministry of Health and Child Care, along with a myriad of partners, implemented a model they called “Stop the Bus”—in which trained staff travel around rural communities to provide HIV, voluntary family planning, and reproductive health services to young women.
For the full story of this program, we spoke with Taurai Bhatasara from the Ministry of Health and Child Care in Zimbabwe.
Taurai Bhatasara My name is Taurai Bhatasara, and I'm the National DREAMS and Key Populations Coordinator for the Ministry of Health and Child Care in Zimbabwe.
So this intervention is mainly focused on providing youth-friendly services to adolescent girls and young women. We do provide a variety of services that include HIV prevention services. But we also have a section where we then also provide sexual and reproductive health services, that also includes family planning and also where we then also do short-term, medium-term and long-term family planning method provision. So generally this is a model where we are providing the services, using an outreach model, as compared to the static model where people can then come to access services. By this model, we are taking the services to the doorstep of our adolescent girls and our young women.
Narrator The program also focused on high-quality counseling to ensure voluntary and informed method choice. Over a four year period, over 8,500 young women accepted a voluntary family planning method through the program which has largely been attributed to the fact that they could access services in their rural communities without fear of stigma.
We asked Taurai to explain what led to the program’s success. He mentioned several components.
Taurai Bhatasara The first being creation of a youth-friendly environment. If we are to compare this model with this static health facilities where adolescent girls have to go and access services within the facilities in the communities, I would then say, with this model, we then had to take services to the areas where adolescent girls and young women ought to be found, thereby reducing the distance that they would have to walk.
And secondly, the other issue is around seeking consent. So when you look at the districts where we were implementing this model, issues to do with culture, norms, religion and tradition. If an adolescent girl or young woman wants to go to a health facility, they have to tell their caregiver—be it their mother or their father—and in many cases they have to be accompanied to go to the health facility.
And the other issue that we then also managed to address by this, is the issue to do with the creation of safe spaces. So, this is where we would have only adolescent girls and young women. These are peers, people of the same age that are coming together to access the services without anyone either looking at them or judging them.
And the other issue that I can speak to is the issue to do with the youth-friendly service provision. Because the nurses that we would go with, that were part of the team that will be in the bus were then also trained on youth-friendly service provision. And then we also then trained them on family planning, using the WHO guidelines on family planning. They were also then experts in terms of communicating with adolescent girls and teasing out the issues that really would trouble the adolescent girls and young women within the community.
Narrator It was also important that they had free access—as most of these clients would not have been able to afford even a nominal fee for reproductive health services. Girls in the community knew they could go to the bus and get a range of services for free, without being judged. We asked Taurai how they were able to promote the bus as a safe space, and how they generated hype around the bus.
Taurai Bhatasara So one thing is that we had what we refer to as “DREAMS Ambassadors.” So these are adolescent girls and young women that stay in the same community, that were engaged and trained and would get a small stipend or an allowance for them to do the work, where they would then go into the community to mobilize their peers to then come and access the services from the bus. So that alone created a sense of ownership in the community to say, “Ah, you know, we are seeing one of our own, one of our own young people working for these particular organizations and also mobilizing young people.”
The second issue is around edutainment. So the day when we want to then go into a certain community, a day before, we would then send either a truck, or an open truck, or a double cab truck branded with banners, but with music, just to go around the community speaking to the adolescent girls, inviting them so that they can come to a certain point, the following day to access services.
And on the day, we would then have a different arts group from the same community as well, coming in to perform—your young upcoming artists also showcasing their talent in the community, amongst their peers as well. So that also then created an opportunity for adolescent girls to also then come.
Narrator DREAMS Ambassadors educated peers on the availability of FP/RH services, and helped normalize seeking family planning and reproductive health care. Establishing the bus as a safe space—and promoting it through entertainment—made it very popular with adolescent girls and young women in the communities. In addition to mobilizing young women to visit the bus, the program team also needed to make sure they were receiving high-quality care once they got there.
The program trained the nurses on responding to the needs of adolescents and young women without judgment. Having nurses come from outside of the community helped ensure confidentiality and reduce the stigma and discrimination associated with contraception for adolescents.
The “Stop the Bus” program also involved influential members of the community to address social norms. And they learned that being accepted by the community involved more than just going through district government. They had to engage the community gatekeepers to find true acceptance in the community.
Taurai Bhatasara So we did everything that we needed to be done. I went to the district administrator, submitted our papers and we were given authority to go around into the community. So our assumption was based to say, well, if we are given or for it to, to go around, we would just be received by the community because we have received that authority from that particular level. But there are other nuances that you then started to see that, you know, when you then go down to the community level, they are community gatekeepers.
So you would then also engage different gatekeepers. So your traditional leaders, your religious leaders, your counselors, and your influential people within the communities. That's when we started to get buy-in and started to see quite a number of adolescent girls and young women coming out of their homes to then go and access the services.
Narrator We asked Taurai what advice he would give to others planning a similar program.
Taurai Bhatasara So for me, engaging the community and making the community aware and being part and parcel of the program would really make some significant changes into the program. That can only open doors for adolescent girls and young women to access services within the communities.
So I would flag issues to do with the community engagement, as a priority, but also then not underestimating the involvement of young people or the adolescent girls and young women themselves in taking leadership to mobilize other adolescent girls and also taking leadership in terms of being volunteers and peer educators also in the program.
Narrator Taurai explained that another element that made the bus program successful was partnership.
Combining forces among different health areas and sectors helped save resources and led to better quality services.
Taurai Bhatasara So with the Stop the Bus model, we then reduced the number of individual partners going into the same community. Thereby using either one bus, people get into the bus or get into a certain car. We reduce the number of cars going into the same community. We have reduced their per diems or their allowance that are given to the teams that are going on outreach. So it also then increases the number of commodities that you then procure and also give to the adolescent girls or to the beneficiaries themselves.
So I would say it's a model that allows partners to see each other as organizations that can complement each other rather than compete with each other because they are serving the same adolescent girl, they are serving the same young woman in the community.
Narrator We concluded our conversation with Taurai by asking him to explain what he sees as the benefits of providing adolescent-responsive contraceptive services.
Taurai Bhatasara When we then combine the service for the general population and everyone else, sometimes we miss opportunities for adolescent girls and young women that are specifically opportunities that are designed for them. So creating these spaces that are specifically for them can only improve access and utilization of services, can only create safe spaces where adolescent girls and young women can freely discuss issues that affect their lives without either being discriminated or being stigmatized based on their age or on the services that they will do, they would also then require.
Narrator Several themes are woven throughout the stories in this episode: acknowledging and addressing social norms that can prevent adolescents from accessing care and achieving their reproductive intentions, addressing provider bias by addressing gaps in clinical and professional development, meeting young people where they are, engaging community leaders, and working across sectors. Also—all the programs we discussed in this episode involved young people directly in the planning and implementation. From the rovers in Kenya, to the brigades in Mexico, to the DREAMS Ambassadors in Zimbabwe, we heard about the innovative ways that young people can advocate, educate, and mobilize communities to improve their own family planning care.
This episode concludes our focus on adolescent-responsive services. We hope that these stories will help inform your own programs, and influence decision making to adapt some of these models for other settings. Please join us next time for episode 5, where we will zoom out a bit and feature some programs that scale up family planning services and improve health systems overall.
These stories are part of a series of 15 stories selected from a global competition hosted by IBP and Knowledge SUCCESS to highlight experiences implementing High Impact Practices and WHO guidelines. If this episode left you hungry for more, we encourage you to read the other stories on the IBP Network website.
Inside the FP Story is a podcast produced by the Knowledge SUCCESS project and the World Health Organization’s IBP Network. This episode was written by Sarah Harlan and Anne Ballard Sara, and was edited and mixed by Elizabeth Tully. It was supported by an additional team, including Nandita Thatte, Ados May, Carolin Ekman, and Brittany Goetsch.
Special thanks to our guests: Paula Tavrow, Lorena Santos, and Taurai Bhatasara.
To download episodes and to find additional links and materials, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher. You can also find Spanish and French transcripts at KnowledgeSuccess.org.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
Thank you for listening.