Promotion of Sexual and Reproductive Health and Rights and Nutrition for Adolescent girls

Expected results are: (1) improved quality of sexual and reproductive health services offered to adolescents in the health and social promotion centres of the health regions supported by the project; (2) increased use of reproductive health services, especially family planning, nutrition and voluntary HIV testing by adolescents; and (3) creation of an environment conducive to sexual and reproductive health of adolescents, including recognition of their rights.

The project’s ultimate outcome is to improve adolescent sexual and reproductive health (SRH, SSR in French). Doing so requires improving service quality, improving service utilization by adolescents, and creating an enabling environment for better adolescent health, including respect for their rights – the three intermediate outcomes of the project.

Intermediate Outcome 1: Service quality.

First, quality of adolescent health services shows many weaknesses at present. For example, among Burkinabe women currently using contraceptives, only 53% were counselled about the side effects (PMA 2020). Moreover, when considering service quality, Burkinabé adolescents emphasize provider attitudes, privacy/confidentiality, and availability of diverse methods. Access to such ‘youth-friendly services’ is extremely limited (Castle 2016). One assumption underlying the link between this outcome and the ultimate outcome is that public-sector services are adolescents’ main sources of care and information. Overall, the public sector is by far women’s main source of family planning (FP) and other SRH services, and private clinics are less likely to have FP methods in stock (PMA 2020). However, unmarried adolescents tend to prefer buying contraceptives from pharmacies or private providers, which they find more anonymous (Castle 2016). Meeting the urgent need to increase FP coverage requires complementing the public sector with private-sector models, such as that of Marie Stopes Burkina Faso (MS/BF). This also mitigates certain risks of public-sector reliance: funding cuts, changes to priorities, or an emergency that diverts resources. These will be further mitigated by the involvement of Ministry of Health (MOH) leaders in the project and advocacy for a sustained commitment to adolescent SRH.To improve service quality, we will focus on the public sector (health services and youth centers) but also include private-sector platforms through MS/BF, which reach more unmarried adolescents and offer more long-term FP methods. Using these platforms ensures equitable reach, as they are present nationwide, even in remote areas, and are free or low cost. There are several issues with service quality as present: providers have not been trained on adolescent-specific health issues, many lack skills to counsel this population, public facilities do not provide some FP methods, and many youth centers are defunct, lacking necessary materials and staff. Adolescents are rarely seen as a separate constituency, so services and tools are not adapted to their needs/preferences. We aim to improve provider capacity through training and mentoring. Training will improve staff knowledge of adolescents’ needs and how to meet them, filling essential gaps. Mentoring will be useful as much of service quality hinges on “soft skills” of interpersonal communication, empathy, and ensuring trust as opposed to hard skills and knowledge. In addition, supportive supervision will help staff assimilate training content, apply it on the job, and retain their new skills. The training curriculum will be adapted through participant feedback, helping to ensure their comprehension. Mentoring will only improve quality if it is high quality, sustained, and relevant. This will be assured through a consultative process of curriculum development, followed by monitoring and supportive supervision.Two key assumptions underlying the links between training and improved service quality are that quality gaps can be addressed through training (and do not require other strategies like increased numbers of service providers or incentives) and that health staff, once trained, will remain in their roles. The first is sound: the materials needed for providing services are within the government’s set of agreed inputs and usually in stock with few shortages. The second is an occasional issue: health workers change zones or leave for more lucrative jobs. It will be mitigated here by refresher trainings and advocacy to provide appropriate health worker support. Youth centers allow adolescents to seek advice without going to a health post. Our hypothesis is that improving the quality of SRH services at these centers will increase utilization. The assumption is that quality (as opposed to willingness or permission to use them) is the barrier restricting their use at present; indeed, many are effectively defunct. To increase their functionality, we aim to refurbish them physically and in terms of staff (through training). Risks to this strategy are that the facilities, once refurbished, will be claimed for alternative uses and that midwives will leave after being trained; the former will be mitigated through an initial community consultative process and the implication of the community in the refurbishment; the latter will be addressed through advocacy with the MOH about incentives.Finally, improving availability and use of adolescent-specific health data will help improve service quality by giving decision-makers the information needed to revise services to better meet adolescents’ needs and track progress towards desired outcomes. Partners’ experiences indicate that the government makes considerable use of data for decision-making (e.g., for neglected tropical diseases and vitamin A supplementation) and is committed to improving health information systems. This project will benefit from lessons learned through these other initiatives with regards to improving data availability and use for policymaking. These efforts will be further supported through project advocacy activities and inclusion of policymakers in the steering committee, where data use will be discussed.Anemia rates among schoolchildren in Burkina Faso are very high, at approximately 69%. For this reason the project team will provide supplementation in iron and folic acid along with deworming to middle school students in one of the HKI regions of intervention. This is a public health measure recommended by the World Health Organization (WHO)in countries with high levels of anemia (i.e., in excess of 40%). The goal of this activity is to reduce the risk of anemia, and all that it entails, for adolescents. The supplementation activity will be accompanied by nutritional education using proven techniques, including negotiation skills and counselling focused on individual needs. This activity will enable the various actors involved to improve their SBCC skills, which will also benefit the sexual and reproductive health aspects of the project.

Intermediate Outcome 2: Service utilization.

Existing services in Burkina Faso remain under-utilized by adolescents, with contraception use at only 6.7% among those 15-19 (half of whom wish to delay pregnancy) and even lower levels of use of health facilities for preventative and curative care (MOH 2014). Current unmet demand for FP is 45% among women of childbearing age (PMA 2020). Adolescents get most information about FP from their peers and often lack information from experienced contraceptive users. The assumption behind the link between increased utilization and better health is that services are high quality; this is addressed in the first intermediate outcome, which places significant weight on assuring ‘youth-friendly’ approaches. An additional assumption is that adolescents’ needs can be met by a functioning, youth-friendly system. For most needs (contraception, prenatal care) this is likely to be the case: these known solutions can be delivered by functioning health centers with trained staff and appropriate tools. For others (e.g., inadequate menstrual hygiene management, sexuality-related psychological issues), other interventions are likely needed (e.g., WASH infrastructure, improved psychiatric care). Those offerings are beyond this project, but we will encourage their development by creating an enabling environment. To improve service use, the project will improve adolescents’ knowledge of SRH and access to services, including HIV screening. There is evidence that a lack of knowledge is a barrier to use. For example, 43% of Burkinabe women have not received information on FP in the past year (PMA 2020). While general awareness of contraception is high, detailed knowledge is limited. Among adolescents, myths and rumors concerning different methods and their risks are widespread. Adolescents are particularly concerned about the impact of contraceptive methods on future fertility, given cultural pressures to produce children (Castle 2016; MSI/FHI360 2016). Knowledge will be improved through a multi-media strategy, using health centers, a call line, radio shows, communication materials, interpersonal communication, community events, and social media, each of which will reach different adolescents: younger and rural adolescents are less likely to own phones and unlikely to access social media but more likely to listen to radios at home. Those living near health centers will be able to receive in-person support while those in more remote areas will benefit from the call-in line. Impersonal channels are effective in light of the sensitivity of the issues addressed: many adolescents feel uncomfortable discussing topics like STDs in person. To mitigate the risks of being perceived as promoting promiscuity and ‘Western values’, messages will be carefully pretested with target audiences, and there will be extensive vetting of all content. Formative research at the start of the project will tailor the content and channel to local norms.To improve service access, the project will deliver SRH services through health centers, MS/BF midwife outreach, colleges, and HIV screenings. Such a diverse range of approaches will allow us to reach a large majority of adolescents (including the many who are out of school). Risks to the first two strategies are as noted above (lack of funding, personnel leaving) and will be dealt with similarly. There is a risk that providing services through colleges could generate backlash by parents or staff if services are seen to promote promiscuity. This will be mitigated through consultative processes and awareness-raising. Screenings may be underutilized if adolescents feel they will be stigmatized if seen to attend. This will be mitigated by holding events in discrete locations and pairing them with other non-STD-related activities.

Intermediate Outcome 3: Enabling environment.

An enabling environment is crucial to improving adolescent SRH. Without public support for their rights, adolescents will not be empowered to demand and use health services or make decisions that can prevent adverse SRH outcomes. For example, many girls will still be pressured into early marriage, risking high-risk pregnancies. Sustainability and achieving greater policy enforcement also require broad support. It is thus essential to shift norms to create a cadre of advocates for adolescent rights. One assumption underlying this causal chain is that community-level awareness can impact adolescents’ choices. This is evidenced through past qualitative research by the partners, which reveals the extent to which family and community members (e.g., parents, traditional leaders) influence young people’s decisions. For example, while young women must have permission from their husbands to use contraception, the mother-in-law often applies pressure to produce grandchildren and religious leaders send messages that extra-marital sex or contraception use is taboo. Community leaders may exert pressure towards early marriage and fertility (MSI/FHI360 2016). One risk with this strategy is public backlash against such efforts (for example, if the content is perceived as threatening to traditional norms). We will mitigate this by using participatory approaches for awareness-raising and ongoing consultative processes for developing content, and by integrating input from community leaders and members.We will seek to create an environment favorable to adolescent SRH and respect for their rights by raising awareness among parents, husbands, leaders, and teachers and improving adolescents’ involvement in assuring their SRH rights. One assumption underlying this link is that these constituents represent the main forces shaping the environment for adolescent SRH. As noted above, while there may be other outside influences (e.g., mass media), most Burkinabe adolescents’ lives are centered within their community, where relatives and local authority figures are the main thought-leaders. Moreover, parents and older relatives are key in deciding when a girl will marry, and the husband plays a crucial role in deciding about contraceptive use. This objective will be met through teacher training, community campaigns on early marriage costs and advantages of gender equity, training for parents’ associations on adolescent SRH and rights, and support to radio stations to diffuse content on these topics. For the first three, activities will use participatory techniques, as HKI’s work with the gender-transformative curriculum Nurturing Connections (Cultivons les Relations) and the Husband School approach have shown that participatory approaches are effective at shifting deep-seated beliefs, such as those related to gender. For all of these activities to create an enabling environment, those targeted must be willing to act on the new information. HKI’s experiences confirm that careful formative research and consultation, participatory training, and a rights-centered approach can lead to positive changes in social norms. To further support the enabling environment, we will put in place clubs to teach adolescents about SRH and their rights, encouraging them to be involved as advocates and peer educators. This assumes adolescents will allowed to participate and will then feel able to voice their rights within the community. We will facilitate this and ensure a Do No Harm approach through simultaneous awareness-raising activities, aiming to educate others in the community on adolescents’ rights and build support for such an approach. Major risks are community backlash or adverse consequences for adolescents involved (e.g., seen as being promiscuous). Our participatory approaches are intended to minimize this risk by keeping parents, grandparents, teachers, and community leaders informed of the activities’ objectives and earning their support. In the unexpected event that resistance grows, special consultative groups, focused on community leaders, will be formed to understand how to better address these crucial but sensitive issues.

Results obtained as of December 2020 include: 1) the quality of sexual and reproductive health services offered to adolescents has improved through the training of health care providers in three districts which made it possible to train 65 providers (including 30 women) . Of these 65 trained agents, 40 providers (including 21 women) scored at least 85% on the test following the training. Formative supervision of health workers was carried out, with 219 supervisions having taken place during 2020; 2) teacher training continued, with 30 project contact individuals trained (19 of whom are women from schools); 3) 390 school clubs comprising 7,800 members have been set up in 66 intervention establishments. Each club benefited from two events related to the themes of reproductive sexual health and 109 recorded programs on early pregnancy and gender equality were broadcasted; 4) seven listening centers for young people and two school infirmaries received equipment for the continuity of clinical and recreational activities in these centers during the year of 2020. 833 health centers benefited from communication kits that promote adolescent and youth reproductive sexual health; 5) 27,784 calls were received at the call center and 90% of the questions asked by adolescents were related to sexual and reproductive health in general, and family planning in particular; 6) 36 voluntary HIV testing centers continued with routine activities integrating sexual reproductive health services.