2004-3&4 A model for access



	*Sexual Health Exchange 2004-3&4* A model for access to reproductive health education and services for adolescents in Managua, Nicaragua Migdalia Molina Santeliz, María de la Cruz Silva Cajina & Nicholas Frost One of the main challenges facing those who work with adolescents in Nicaragua is that they rarely use the sexual and reproductive health and medical services they need. Within this context, Marie Stopes International (MSI) and MSI-Nicaragua have, since 1999, implemented two consecutive projects, designed to provide IEC (information, education and communication) training and sexual and reproductive health services to adolescents through NGOs and local organizations, particularly in Managua district. MSI-Nicaragua's first project was based on a social franchise model – using alliances with local organizations and institutions that work with adolescents – that aimed to provide adolescents with access to IEC and basic services; train youth and adult peer educators in basic sexual and reproductive health topics and methodology; and test a new model for IEC and service provision to adolescents. Building on the experiences of the first project, a second MSI project is currently testing and evaluating an informal educational framework and a collaborative model, including the public sector (Ministry of Health and municipalities), the private sector (MSI-Nicaragua and participating NGOs) and intended audiences (adolescents, parents, adult leaders, community groups). The second project makes use of two mobile units, each staffed by a nurse/educator, a psychologist/educator and a driver. The units visit schools, organizations working with adolescents and community centres on a monthly basis, providing participatory education to groups of up to 60 adolescents, as well as individual services, such as youth-friendly consultations in a private space. Unit staff also provides training to adult and youth peer educators. The nurse/educator provides basic care, family-planning counselling and, where necessary, referral to local health centres and MSI-Nicaragua's service centres for more specialised care, including treatment of STIs and examinations. Psychological services are provided on an individual, couple, family or group basis. Educational topics covered include life skills, self-esteem, violence and conduct, addictions and sexual and reproductive health. Counselling is provided for pregnancy, STIs, domestic violence, and relationships, among others, and family planning advice is oriented towards barrier methods. Services and education are provided free of charge. Ensuring continuity of care The referral network is based on a close relationship between private and public sectors, including the Ministry of Health, to ensure appropriate and friendly services for adolescents. For this purpose, initial and follow-up training is provided to service providers. Central to the referral network is peer referral of adolescents to the mobile units. Upon referral to local health centres or MSI-Nicaragua centres, peer educators are expected to accompany the adolescent to ensure continuity of care. The system also includes counter-referral, where the health centre provides information to the mobile unit to ensure follow up. Community fairs in communities and schools have been successful in providing information and a safe space for discussing sexual and reproductive health issues. They provide a low-cost, low-infrastructure and informal environment to provide IEC to large groups of adolescents through informational brochures, individual and group information, and puppet shows. The project has initiated activities in five educational centres, expanding to over 17 in the three years of the project. Keeping the project informed and cost-effective Both MSI-Nicaragua and MSI have been continuously monitoring project activities to ensure adequate collaboration and communication among participating institutions. Regular meetings are held to discuss project results to date, successes, lessons learned and ensure proper functioning of the referral network. Based on a mid-term evaluation of the current project in November 2003, a number of recommendations were suggested and implemented, including: Consistent participation of peer educators in the referral and counter-referral aspects of the referral network Extension of IEC to parents, along with training of peer educators to address this group Inclusion of skills in peer-educator training to encourage behaviour change in accordance with individual realities, age and sex Development of a code of conduct to ensure role-model behaviour by peer educators Differential information for young men and women Monitoring of the quality of information provided by peer educators and monitoring adolescent behaviours to measure the impact of IEC Increased counselling for STI prevention, targeting couples and groups Promotion of the use of mobile-unit services to encourage information-seeking among youth who are not yet sexually active Training service providers in adolescent-friendly health services Encouraging peer educators to develop initiatives that include sexual and reproductive health issues within their community, outside of the project framework; and Enabling the use of the educational manual within other existing networks and organizations. Sustainability and replicability of the approach The aim of both projects is to achieve social, rather than financial, sustainability, ensuring continuation of activities among adolescents upon termination. Key elements to ensure social sustainability include the development of the educational curriculum; the training of youth and adult peer educators, including school teachers; basic service provision within organizations and schools that are active within the permanent network with the Ministry of Health; and improvement of quality of care for adolescents within existing health services. MSI-Nicaragua anticipates that, with some technical assistance, the trained promoters can become fairly autonomous. In general, project sustainability seems to be assured with continued interest and intention from participating organizations, the Ministry of Health and peer educators. Replication of this approach for the provision of sexual and reproductive health information and services by similar organizations in other countries is certainly possible, but success depends on a number of factors. Most importantly, strong staff commitment and a high priority to health are crucial. Sexual and reproductive health work should be integrated in the organizations' core activities, and not be seen as a separate project. Furthermore, efficient coordination mechanisms with all stakeholder organizations are vital. And finally, close follow-up and support for the adolescent peer educators is necessary, e.g. through free medical services, refreshments, travel costs, equipment and recreational activities. MSI's social franchise model for IEC and service provision has demonstrated the importance of sexual and reproductive health work for adolescents. It created a safe space for adolescents to understand their sexuality, increase their knowledge and modify their attitudes on sexual and reproductive health issues. The participatory methodology was a key factor for success. Project results so far are encouraging, showing that positive impacts can be achieved and sustained if adolescents identify with the project and are keen to participate, and provided there is adequate support and follow up by the implementing organizations. Migdalia Molina Santeliz and María de la Cruz Silva Cajina, MSI-Nicaragua; Reparto San Juan, 1 c. al este, 1 c. al Norte, Casa No. 252ª, Managua, Nicaragua; e-mail: msinic@ibw.com.ni ; and Nicholas Frost, Senior Programme Support Manager, Marie Stopes International; 153-157 Cleveland Street, London W1T 6QW, United Kingdom; e-mail: nicholas.frost@mariestopes.org.uk
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