Developing a Youth Participatory Model for Community Outreach - Case Study Example

Jamaica Family Planning Association (FAMPLAN): Developing a Youth Participatory Model for Community Outreach 2006 Executive Summary Jamaican Family Planning Association (FAMPLAN), affiliated to the International Planned Parenthood Federation (IPPF) is the pioneering non-governmental organization in Jamaica. Headquartered at the St. Ann parish, it distributes contraceptives as well as provide clinical family planning services like vasectomies and tubal ligations and counseling for reproductive health and HIV/STD protection as well as other healthcare services like tests for diabetes and hypertension, which has a serious impact on reproductive health. It also has literacy and youth uplift projects to empower the distressed and uneducated youth of Jamaicans to have a better life. Despite targeting the youth from less privileged families and innovative programs like the male clinic and the adolescent clinic, FAMPLAN has been experiencing lower client visits over the years. The concern for the FAMPLAN management is increasing client visits without incurring more costs since the organization is crunched for funds. The weak points of FAMPLAN has been identified as insensitive and prejudiced staff, negative social perception regarding accessing family planning services, particularly by the adolescents and lack of infrastructure. FAMPLAN cannot expand geographical spread for lack of funds, neither can it initiate education campaigns on the mass media. Adolescent reproductive health in Jamaica is negatively affected by lack of support at school, home and community. First, there is a large number of youth out of school and the drop-out rate is high. Lack of livelihood and economic sufferings has a strong correlation with early initiation into sexual activity as well as teenage pregnancy. Second, there is minimum parent-child communication regarding issues on reproductive health. Third, there is a strong prejudice among the service providers as well as the community against adolescents accessing family planning services. There is a strong need for improving the quality of services, sensitizing and training of the staff, developing youth-friendly communication campaigns and integrating other youth facilities with family planning services. I propose a youth participatory model that would empower the youth as well motivate them to demand more accountability on the part of FAMPLAN staff. Recommendation The youth participatory model for FAMPLAN would be based on the following principles: Formation of core groups of youth in demarcated rural and urban communities Training of the core group in sexual and reproductive health Empowering the core group to initiate peer education, counseling and referral services Sensitization and training of FAMPLAN staff Support through youth-oriented communication message Table of Contents Page I. Introduction 5 a. A pioneer in reproductive health services in Jamaica 5 b. Need for a strategy to increase service utilization 6 c. Resource constraints 7 d. Youth Participatory model 9 e. Client service 10 II. Adolescent reproductive health services 11 a. The major issues in Jamaica 11 b. Experience from other countries 12 III. Strategy for developing the youth participatory model 16 a. Planning 17 b. Implementation 18 IV. Feasibility of the youth participatory model 19 a. Benefits of targeted services 19 b. Cost efficiency 20 V. Summary and Recommendations 21 Works Cited 22 I. Introduction a. A pioneer in reproductive health services in Jamaica The Jamaica Family Planning Association (FAMPLAN), located in the Parish of St. Ann, has spearheaded the provision of family planning services in Jamaica for over forty years. FAMPLAN has two clinics at Kingston and St. Ann as well as satellite clinics that provide integrated family planning and HIV/STD services. Besides contraceptive distribution, FAMPLAN has various family planning services like vasectomies and tubal ligations as well as literacy and education counseling services for adolescents and parents. Its outreach programs focus especially on adolescents and men (Hardee, 1998). It targets children of age 10-14 who are at risk of dropping out of school, adolescents who are not attending or have never attended school, parents of adolescents who are not gainfully employed, most of whom are from the lower economic class including pregnant women, battered women, teenage mothers and those needing contraceptives. FAMPLAN aims to provide not only reproductive health services but make the lives of the distressed Jamaicans a more fruitful and healthy life. Children, youth and families living in distressed neighborhoods are at risk or facing critical problems such as child abuse, school failure, teen pregnancy, domestic violence, substance abuse, high illiteracy rate and mental health disorders. As a result, family life is disrupted and individuals are unable to reach their potential and become responsible family members, workers and contributing citizens. FAMPLAN’S mission is to reach out to these individuals and empower them through their various programs to lead productive and fulfilling lives. FAMPLAN has integrated several programs in the family planning clinic over the past years, providing other services like tests for blood pressure, blood sugar and urine sugar as well as breast examination, weight management, etc. to increase family planning service utilization. FAMPLAN helped set up the national family planning program and continues to supplement to the government system by providing sexual and reproductive health information and education, offering services in peripheral communities outside the scope of the national program and providing voluntary sterilization. However, the outreach program of FAMPLAN, like other non-governmental organizations (NGOs), has been critically dependent on donor-funds. Peggy Scott is the principal decision-maker of FAMPLAN. She takes decisions on the organization’s goals and policies in collaboration with other executives, who are overseen by a board of directors. She directs the activities of various departments and reports to the board of directors. Each year an Annual Members Meeting is held for the purpose of updating members and staff of the organization on key issues or new developments within the organization and address how donations is or will be utilized. b. Need for a strategy to increase service utilization Despite its pioneering role, FAMPLAN has been experiencing lower client visits during the recent past. Especially, adolescent client visits are falling. The experiment with special adolescent clinics, too, failed since there is a perception that adolescents go to there either for abortions or to treat for HIV/STD. The male clinic conducted weekly, on the other hand, has been more successful after integrating with other services for diabetes, hypertension and prostrate cancer (Hardee, 1998). Clients, particularly adolescents, at FAMPLAN do not feel comfortable going to the clinic because of the following issues: Privacy and confidentiality Issues – the clinic is viewed as a center for treatment of sexually transmitted disease or for abortions, inhibiting many including married couples Unfriendly/judgmental staff – the staff is not trained enough to handle family planning services, particularly adolescents Lack of sophisticated equipment – the clinic does not have access to advanced diagnostic and care equipment, particularly for cervical and pelvic cancer Affordability – even the nominal price is found prohibitive for the poor who can access government health centers free of cost Accessibility – nearly 50% of Jamaicans live in rural areas and the clinics, located in urban areas, are not accessible to them. FAMPLAN wants to initiate a strategy to motivate the adolescents to use its services more intensively and productively. However, since a large part of this targeted client segment is uneducated – mostly semi or illiterate – the strategy needs to be well thought out. Besides the fact that FAMPLAN has to operate under conditions of a stiff budget constraint, the outreach program needs to be simple to easy to understand in order to be communicative. c. Resource constraints FAMPLAN is affiliated to the International Planned Parenthood Federation (IPPF), from which it gets 27% of its annual budget. The remaining funds are received from international donors (31.97%), clinical sales and services (23.13%), donations and rent fees (10.12%) and other sources (7.76%). The IPPF does not stipulate prices of clinical services offered. The financial administrator proposes the prices that are vetted by the Board of Directors. The costs are generally lower than that charged by private doctors but more than government health centers which provide services are free of cost. FAMPLAN organizes fundraising programs – St. Ann Committee Raffle, Easter Bun Sales and Jumble Sale – once or more a year, depending upon the number of items available for the Jumble Sale. Overall, FAMPLAN has a balanced budget. Sometimes, the charges for various services at the clinic cover the costs of provisions but this is usually an exception and not a rule1. Even while recognizing the urgent need for expanding the outreach program, FAMPLAN does not have the financial resources to organize large-scale communication activities like through the mass media, more mobile clinics, etc. It does not have any government funding. Although the donors do not interfere in the actual functioning, there are broad guidelines that FAMPLAN has to follow and cannot deviate too much to devise its own strategy. FAMPLAN is also constrained in its human resources. Family planning services become ineffective if the service providers at the delivery points are not adequately trained. Availability of trained reproductive health counselors is grossly inadequate in Jamaica, especially since training programs have virtually ended with the completion of the World Bank funded project in 1998 (Hardee, 1998). The need for training is amply proved with the success of the integration of STD prevention counseling with family planning services over 1993 to 1996 that was followed by extensive participatory training among service providers who had to break their mental barriers with STD patients (Hardee, 1998). Reproductive health services all over the world face the same problem of prejudice among the staff (USAID, 2005). FAMPLAN now needs to go to the next stage of development by which the stigma associated with adolescent family planning services may be overcome. For this, it needs to utilize all its resources to train the manpower. d. Youth Participatory model In order to reach out to a large section of young people in Jamaica, FAMPLAN should adopt an inclusive program in which the adolescents themselves play an important role so that there is a sense of belonging and motivation. A participatory model may be developed with minimum investment and maximum outcome. For such a model, all stakeholders need to participate in the system. The clinics may increase the participatory role of the youth in their functioning through focus groups, increasing clinic space for the youth as well as redecorating the clinics with a youth-friendly approach, provide more services for teenage pregnancy and sensitization of the staff to the needs of the youth. For the participatory model to succeed, consensus-building among the various stakeholders is essential. The participatory model has been found to be effective in increasing empowerment and accountability of the youth. Community-based participatory model is all the more effective since community knowledge about reproductive health issues has long term linkages on general awareness of the youth. Adolescents themselves are then more likely to increase the knowledge base regarding various issues of sexual relations. The participatory model empowers the youth to make strategic decisions regarding their own health, demand accountability from service providers and in general the social structure and gender norms in sexual relations (World Bank, 2004). e. Client service In addition, to achieve better service utilization, FAMPLAN needs to influence individuals, families and the community towards a better reproductive health behavior. FAMPLAN needs to adopt a client service approach that hinges on the following: Improve quality of services Sensitization of service providers Increase knowledge about reproductive health The range of services is an important issue for higher client visits. FAMPLAN provides a wide range of clinical and non-clinical family planning services as well as other literacy and training programs for the youth. In order to greater utilization of these services, it needs to reach out a wider audience, either through direct communication or through the media or other modes. FAMPLAN has had some success with the male clinics and integration of other health services. However, client visits may be increased even further if the number of days of operation is increased from once a week, especially for cancer treatment. It has already been discussed that stigma associated with receiving family planning services acts as a major deterrent of visits, particularly by adolescents and women in need of HIV counseling. Service providers should be sensitized to show much greater empathy. Individual and community knowledge about prevention of STD/HIV is crucial, though not sufficient, for adopting a successful family planning service. A youth-focused approach with increased, accessible and friendly services, in the presence of individual and community knowledge about reproductive health, is needed to increase service utilization at FAMPLAN. This, in the long run will be reflected in better sexual behavior, particularly among adolescents as well as more productive lives (Russell-Brown, 2001). II. Adolescent Reproductive Health Services a. Major Issues in Jamaica According to Reproductive Health Survey in Jamaica, 1997, contraceptive prevalence rate among women in Jamaica was 48% while that among married women was 62.8%. The median age of sexual debut among women was 17.3 years and as many as 33.7% of the women gave birth before the age of 20 The UNAIDS-2004 figures showed that nearly 22,000 people were estimated to be living with HIV in 2003, women among them numbering 10,000 (USAID, 2006). Sexual intercourse begins at an early age among Jamaicans, particularly among the poor. Adolescent pregnancy rate in Jamaica, at 108 births per 1,000 women, is one of the highest in the Caribbean. Nearly one quarter of births in Jamaica is to teenage mothers. Teenage pregnancy in Jamaica can be directly related to non-use of contraceptives and early initiation to sexual activity (Hardee, 1998). Family planning services in Jamaica needs to target the youth, by designing the communication as well as services as youth-friendly. It is essential to promote the message of abstinence at youth while at the same time ensuring contraceptive security for sexually active youth. Since most contraceptives are appropriate for adolescents, there should not be any prejudice against any particular method and the service providers should have clear guidance on counseling. The service providers should be sensitized on the need for providing family planning services to adolescents, overcoming the stigma of handing over contraceptives to adolescents and unmarried women. The youth should have sufficient knowledge on contraceptive methods through the school and community networks, mass media and other channels. The promotion of dual services of family planning and HIV/STD is cost-efficient and effective. Most importantly, youth-friendly approaches to affordable and accessible services and maintenance of confidentiality and privacy of youth concerns are crucial (USAID, 2005). b. Experiments in other countries The correlation between low-income families living in distressed communities and high incidence unemployment, illiteracy, unwanted pregnancies and other social problems has been visible in most developing countries. With the focus of the research based on the best strategy to develop community outreach and expand utilization of services, this paper reviews sexual and reproductive health and education and other clinical/non clinical services with studies from other developing countries. Sexual and reproductive behaviors during adolescence and young adulthood, whether within or outside marriage, have immediate and long-term consequences, many of which can be emotionally or physically harmful. Many adolescents do not have the ability or social support to resist pressure to have sexual relations, negotiate safer sex, or protect themselves against unintended pregnancy and STDs. The Peru affiliate of IPPF developed the Youth Involvement in Design, Implementation and Evaluation Project or the Youth Education Stations (YES! Project) as community centers run by the youth to provide sexual and reproductive health information and counseling on CD-ROMs and other multimedia platforms. These stations also have referral services. The YES! Stations function with four youth educators each, in co-ed pairs, who have been involved in the entire process of project evaluation, design and implementation. The affiliate also works on the social uplift of out-of-school youth providing workshops, training and talks (IPPF, Western Hemisphere). IPPF affiliates in Peru, Chile and El Salvador use computers to reach out to the youth while the IPPF collaborate with the British Broadcasting Services (BBC) in developing radio and television educational programs on reproductive health all over the world. It has been seen that participatory programs for adolescent reproductive health are cost-effective and efficient. EngenderedHealth and International Center for Research on Women (ICRW), in collaboration with local NGOs, conducted an experiment with the youth in Nepal between 1998 and 2003. The aim was to study the role of empowering of the community through a wide-range of interventions like youth-friendly services, peer education and counseling on improving the socioeconomic conditions of life that included reproductive health of the youth. In the study, communities were actively engaged in the action plan as well as the execution. Under the Nepal Adolescent Project (NAP), surveys were conducted at three controlled site where traditional youth-focused models of adolescent reproductive health (adolescent-friendly services, peer counseling and teacher training) and at eight sites where the participatory model (information and education campaign, adult counseling, youth clubs, street theater, improve the economic livelihood of youth in addition to the traditional tools) was used. Socioeconomic disadvantages of the youth, including gender, wealth, income, rural-urban disparity and marital status were considered in the study sites. Data on the youth in the age group of 14-25 was collected from 965 households at the beginning of the program and from 1003 households at the end. The results showed that the participatory model was more effective at the study sites than the traditional models of contraceptive distribution and other family planning services at the control sites. For example, at the baseline there was considerable difference in the access to prenatal care between rich and poor women while poor women were better off on this count at the end of the program because of improvement in delivery of services. Girls became more aware of modes of HIV transmission through the program. The participatory method increased the social networking among the youth and empowered them to demand more accountability from service providers. Thus, the program that focused not only on providing reproductive health services but an all-round empowerment of the disadvantaged youth has resulted in a greater impact (World Bank, 2004). International Planned Parenthood Federation, Western Hemisphere, too, experimented with youth-friendly tools like making more clinic space available for the youth, developing campaign material specially targeted for the youth, sensitizing the staff and making services more affordable and accessible, in the Caribbean. It aimed for more participatory role of the youth. For example, the Honduras affiliate redecorated the clinic on suggestions from the discussions of a focus group. It has even placed a suggestion box in the clinic reception for improvement of youth-friendly services. In Paraguay, the clinic has a small library, a television with educational videos and consultation rooms in the youth clinic. The local youth were roped in to paint a mural on the clinic walls (USAID, 2006). In Rio de Jeneiro, Brazil, an experiment was conducted to study the impact of intervention for gender-equitable behavior roles among the youth and their effect on HIV/AIDS protection. The experiment was done with three control groups – 1) interactive group discussion led by an adult male, 2) community-wide education campaign focusing on condom use reinforcing the group discussions and 3) intervention of both types were made after the control period. It was found that there were considerable HIV/AIDS risks associated with inequitable gender norms that define masculinity and far better outcome resulted from the combined intervention. At the baseline, 70% of the young men between the age 14-25 were sexually active and 25% of the youth reported STD. Inequitable gender norms were prevalent among all. At the intervention sites, the incidence of reported STD decreased and the decrease was statistically significant at the combined intervention site. The study concluded that education interventions to alter gender roles can supplement HIV/AIDS protection programs very effectively (Horizons, 2006). Thus, education programs on gender roles have an important role to play in youth family planning services. Such studies have been adapted in other countries like India and Mexico. In Barkino Faso, Advocates for Youth and Mwangza Action developed a participatory model in community intervention programs were launched in 20 villages. The program included workshops of young men and women as well as for adults, focus groups, meetings with local authorities and action planning. It was found that infrequent use of family planning services, lack of communication between parents and children and lack of information regarding adolescent reproductive health were the main reasons behind the problems. The strategies identified were peer education, activities to improve parent-child communication, utilization of media and implementation of youth-friendly family services. Results showed that there were fewer sexually active youth reporting to have casual partners, the number of young people with one partner increased from 47% to 67% and the proportion of sexually active youth reporting use of condom increased from 51% to 73% (Advocates for Youth, 2004). III. Strategy for developing the participatory model To develop a participatory model for youth programs, FAMPLAN should take the following steps: a. Planning The general model of contraceptive provision and other family planning services that are targeted for men and women are applicable for the youth as well. In addition, the model involves a planned strategy of youth-targeted programs. The planning process would involve Understanding the health status of the youth and their healthcare-seeking behavior Involve the youth in focus groups, peer education programs Parent counseling for increase in parent-child communication on reproductive health issues Developing a timeline and logistics of providing youth-centered programs Identifying the core service package and their costs Correlating youth-centric healthcare facilities with other programs like counseling for drug-related problems and violence b. Implementation 1. Action groups FAMPLAN may organize action groups consisting of the youth in various rural and urban areas. These youth may set up centers, the infrastructure of which may be organized with the help of the local community, church, school, etc. These core groups of youth may be trained extensively in sexual and reproductive issues, contraceptive use, the risks associated with early sexual initiation and multiple and casual partners. Thereafter, the core group can in turn initiate peer education programs, group discussions, counseling services and referral services. 2. Key messages Family planning messages targeting the youth is essentially different from the general message. The youth who are not yet sexually active should be educated about the necessity for abstinence and sexual delay. Those who are sexually active should be educated about the contraceptive options. Since most options are appropriate for adolescents and young adults, there should not be any prejudice for or against particular method. In addition, sexually active youth should be informed about the importance of single sexual partner and delayed pregnancy as well as risks on reproductive health. 2) Accessibility and affordability There should be contraceptive security for the youth at the main as well as satellite clinics. Prices of contraceptives are critical for the youth so the pricing should not be a hindrance. Youth clinics should be accessible and conveniently timed so that it does not impinge on school hours. Affordable and accessible reproductive healthcare is an essential enable factor for improved health. 3) Sensitizing the staff The staff should be sensitized to develop empathy for the youth who are accessing family planning services. Particularly unmarried young women face prejudice while accessing the clinics. 4) Integrating youth services Youth counseling should be integrated with other services like physical examination, clinical services, contraceptive supplies, pregnancy testing, cervical cancer and HIV/STD screening, antenatal, delivery and postnatal care, post-abortion care and referral services. 5) Linking youth reproductive health with youth resilience It has been found that school, home and community setting influences youth behavioral patterns. Early initiation to sexual activity, substance abuse and violence are all related to lack of resilience in the youth which in turn is the result of a lack of comfort at the home, school and community setting. In Jamaica, the large number of out-of-school youth and lack of a viable livelihood has been found to be positively related to early sexual activity. Rather than focusing on the risks and dangers of sexual activity, long-term policies to increase the resilience of the youth, through care, support, appreciation and empowerment goes a long way to improve adolescent reproductive health (Scott-Fischer and Campbell-Forrester, 2000). Effectively reshaping service delivery to ensure affordability and accessibility to the youth will help maximize the reach of family planning and other services. Integrating family planning and other health services can help meet the special needs of different population and bring family planning services to new audiences. Improving contraceptive counseling and ensuring easy access to other non clinical services can make the goal of informed choice a reality. Finally, strengthening day-to-day service delivery can improve the quality of care that family planning clients receive (PATH, UNFPA 2006). Behavior change communications, including client education, community mobilization and mass media, has the potential to change community norms as well as individual attitudes. It can also increase knowledge and motivate potential clients to act. At the same time, compensating clients’ out-of-pocket costs and waiving fees can remove the economic barrier that discourage individuals from seeking family planning services and other integrated services. IV. Feasibility of the youth participatory model a. Benefits of targeted service Adolescent reproductive health status is the most crucial factor in family planning services in Jamaica. The youth participatory model enables a wide communication program with minimum investments. The core youth groups can be formed in association with the communities, resulting in a greater sense of belonging and accountability. It will improve the information, education, communication (IEC) platform through the involvement of youth and community groups that supplements services at clinical non-clinical service sites of FAMPLAN. Increase of demand family planning services depends on the social norms. This is particularly true for adolescent reproductive health services. The participatory model aims to encompass the community, influencing the social organizations including schools, parents, peers and service providers. Empowering the youth in the decision-making process of FAMPLAN will motivate them to demand for better service quality. The sensitization of the staff is a prerequisite for greater youth participation. Parent counseling and school networks would improve parent-child communication and school comfort levels that in turn would result in more resilient youth who are more empowered and accountable. Coordinated behavior change policy through the participatory model, involving training of service providers, parents, school teachers, religious leaders and the youth as well as community-based mass media would bring about a positive change in the societal outlook. b. Cost efficiency The youth participatory model would be more cost efficient than alternate models of increasing the number of mobile and stationary clinics, engaging the profit-oriented mass media, incorporating more healthcare facilities. In this model, FAMPLAN can concentrate on strategy planning, training and enabling services. Targeting the youth, the most critical population group as far as reproductive health is concerned, is cost effective since scarce resources can be used for this client set. Although targeting services for the youth diminishes universal access, it has been found that proper targeting ensures equity if supported by targeted information and education campaigns and communication and improved facilities and logistics (USAID, 2005). V. Summary and Recommendation Over the past few years, FAMPLAN has been experiencing lower client visits. Being a donor-dependent organization, FAMPLAN does not have sufficient resources to initiate large-scale expansion of its community outreach program. Although FAMPLAN has experimented with various targeted services like the adolescent and male clinics, integrating HIV/STD prevention programs along with the family planning services, clients are inhibited by the unfriendly and prejudiced staff, inaccessibility of the clinics and the stigma of visiting a family planning services. I propose a targeted youth participatory model for increased information, education, communication (IEC) program. The program will involve Formation of core groups of youth in demarcated rural and urban communities Training of the core group in sexual and reproductive health Empowering the core group to initiate peer education, counseling and referral services Sensitization and training of FAMPLAN staff Support through youth-oriented communication message Since the adolescent population is the most endangered category for reproductive health in Jamaica, I suggest FAMPLAN adopts a targeted approach to service this group, integrating counseling with other youth reproductive health services. Simultaneously, training of staff, parents, community and religious leaders would enable a positive behavioral change in the society that would supplement the empowerment of the youth through the participatory model. Works Cited Hardee Karen, Reproductive Health Case Study, Jamaica, The Policy Project, The Futures Group International, 1997 Russel-Brown, Pauline, A., Adolescent Reproductive Health in Jamaica: A Conceptual Model for Planning and Evaluating Futures Adolescent Reproductive Health Project, The Futures Group International, 2001 USAID, Strengthening Family Planning Policies and Programs in Developing Countries: An Advocacy Toolkit, December 2005 USAID, country Health Statistical Report: Jamaica, June 2006 Horizons, Promoting More Gender Equitable Norms and Behavior Among Young Men as an HIV/AIDS Prevention Strategy, Instituto Promundo, 2006 World Bank, Do Participatory Programs Work? Improving Reproductive Health for Disadvantaged Youth in Nepal, Development Outreach, 2004 http://www1.worldbank.org/devoutreach/may05/article.asp?id=303 Advocates for Youth, Youth and their Communities Take Charge to Improve Youth Reproductive and Sexual Health in Burkina Faso, http://www.advocatesforyouth.org/about/burkinafaso/summary_eng.htm Scott-Fischer, K and Campbell-Forrester, S, Resiliency Factors in Jamaican Adolescents, Caribbean Adolescent Health Survey, 1996 data, 2000 International Planned Parenthood Federation (IPPF) Western Hemisphere, http://www.ippfwhr.org/programs/program_youth_st_3_e.html Read More