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Embracing diversity to improve adolescent sexual and reproductive health in Nepal

Americares will explore youth engagement innovations to create a model for ASRH services in the socially diverse wards of Gokulganga, Nepal.

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What specific problem(s) are you trying to address?

Our community-based earthquake recovery programs have uncovered many barriers preventing access to adolescent sexual and reproductive health (ASRH) services. This is true in Gokulganga which has a high rate of teen marriage and pregnancy. Shyness prevents girls and boys from seeking care. Sex education is insufficient in school. Discomfort and lack of confidence is prevalent among health workers treating adolescents. Families can be judgmental about some ASRH services and may restrict access, especially for girls. Confidentiality is a concern when obtaining services in public, particularly in small villages where a health worker is a relative or friend. Socioeconomic factors also influence which groups have access to health care.

What are some of your unanswered questions about the problem(s) you are working to address?

Does earthquake damage impede delivery of ASRH services? How does the caste system affect a community’s support for ASRH services? Which diverse groups require some program elements to be provided to them separately? What kinds of disabilities, discrimination or abuse are experienced by adolescents and does this affect their needs? What modalities of engagement will resonate best among diverse groups? How can health workers respond to diverse needs to create the most effective relationships?

Explain Your Idea

We intend to dramatically increase knowledge of and access to sexual and reproductive health services for adolescents from diverse groups. An initial human-centered design phase will conduct formative research to uncover what prevents adolescents, especially girls, from accessing ASRH services. By segmenting adolescents that may have particular requirements (such as: male, female, single, married, young mothers, and ethnic groups with influencing norms) we will seek input on what information and services they need and how they want to access them. Findings will help develop culturally accepted communication and facilitation methods. Modalities of engagement to be explored include: drama focusing on ASRH information and increasing comfort with services; experiential games that explore myths, information, values clarification, and decision-making; dignity groups in which adolescents can self-select a peer group for discussing issues of concern; and psychosocial support for anxiety or GBV provided by community health workers. Approaches to creating a supportive environment for adolescent services will include ASRH orientation for health workers as well as facilitated discussions with government and community leaders. Formative research will drive content for the engagement activities, which will likely include topics such as puberty, menstruation, family planning, STIs, sexuality, meeting emotional needs, use of social media and linking adolescents to local services.

Name the three most important ways that your idea will address your identified problem(s).

1) Creating a process for identifying “what works” for the varied needs of the diverse adolescent population will provide a model for use at the village level that is realistic for engaging all adolescents with information and services. 2) Our current programs have generated support at the village level for mental health and psychosocial services, showing that community acceptance for what may be considered ‘taboo’ health services is possible through education and engagement. 3) Exploring how to include health post staff in the engagement process will provide learning around how to create strong relationships between health providers and youth from different backgrounds and circumstances.

How is your idea unique?

We seek to understand the social and gender norms across diverse segments of the adolescent population in a rural community to identify and better address their unique needs. For example, young married women (especially those who are mothers) may feel alienated from activities that focus on single women. Adolescents may not feel comfortable during discussions about ASRH topics with peers, educators or service providers from different castes. Young people with disabilities may not see how the information and services are relevant to them. Those who have experienced GBV often feel shut off from others and ashamed or feel totally disempowered. Through our diversity model of engagement, every adolescent will find a welcoming and comfortable means of obtaining the information and services they need. Through our multi-level approach to engagement with adolescents, community volunteers, health facility staff and community representatives, the entire community is part of the solution.

What are some outstanding concerns or questions that you have regarding your idea?

The recent election of local governments presents both opportunities and concerns. These officials will be included in initial planning, but it is unclear what type of advocacy will be needed. Also unclear is how much time health post staff will have to engage in community ASRH education activities, but the human centered design approach will help ensure our idea strikes a realistic balance. Their participation is key to creating stronger relationships between health workers and adolescents.

Who are your end users?

Our end users include 3,500 adolescents aged 10-19 (both males and females) across six wards of Gokulganga. This will include: -Young adolescents for their perspective about growing up and exploring age-appropriate reproductive health education. (Groups for girls and groups for boys) -Older adolescents will influence how ASRH services are provided and will help establish relationships with health workers. (Groups for girls and groups for boys) -Young women who are married, pregnant or have children will have peer groups established for mutual support. -Adolescents from specific ethnic groups when they need their own space. -Parents, health workers and community leaders will be oriented to ASRH.

Where will your idea be implemented?

  • Nepal

What is the primary type of emergency setting where your innovation would operate?

  • Natural disaster

Tell us more about the emergency setting that you intend to implement in

The 2015 earthquake severely disrupted health services across 10 districts of Nepal, including the community of Gokulganga, where this project is set. Reestablishing health care delivery is taking longer than anticipated and access to services is still limited in many areas. Moreover, attention has focused on restoring basic health services, while the sexual and reproductive health needs of adolescents – a particularly complicated and vulnerable population – has so far been overlooked.

What is your organization's name?

Americares Foundation with Georgetown University’s Institute for Reproductive Health

Tell us more about you.

Since the 2015 earthquake, Americares has rebuilt damaged clinics and hospitals to help restore health services in affected districts. Our team has also implemented community-based mental health and psychosocial programs to generate local capacity to provide services to vulnerable groups. Our team has rich experience in reducing stigma around mental health and creating local psychosocial support capacity. The Institute for Reproductive Health (IRH) at Georgetown University will provide technical support in human-centered design. IRH strives to expand family planning, advance gender equality and involve communities in reproductive health interventions that improve their well-being.

Organizational Characteristics

  • International/global organization

What is the current scale of your proposed innovation?

  • Community - 1+ communities within 1 country

Experience in Implementation Country(ies)

  • Yes, for more than one year.

Expertise in Sector

  • Yes, for more than a year.

Organization Location

Americares is headquartered in Stamford, Connecticut, USA and is locally registered as an international NGO in Nepal. Georgetown University is located in Washington, DC, USA.

What is your organizational status?

  • Registered non-profit, charity, NGO, or community-based organization.

What is the maturity of your innovation?

  • Early Stage Innovation: exploring my innovation, refining, researching, and gathering inspiration.

Website

http://www.americares.org

How has your idea changed based on feedback?

We received helpful feedback from the OpenIdeo community, adolescents and local representatives in our target community. We have incorporated changes to make our idea more impactful, feasible, and effective. We designed a better way to group beneficiaries to achieve maximum impact, decreasing the number of beneficiary groups while maintaining diversity, and only creating groups based on ethnic lines where youth determine they need a separate group. Adolescent girls made it clear that boys and girls should be separated and parents reached as a beneficiary group. We learned that social media is contributing to early marriages and should be included in activity content. Leadership expressed that ASRH skills training among health workers and volunteers is lacking, so a contraceptive technology update, ASRH orientation and values clarification, followed by supportive supervision will be implemented to create strong linkages between adolescent peer groups and their health posts.

Who will implement this idea?

Americares will engage a local NGO (to be confirmed) in our target area to provide 6-10 full-time facilitators to work in the villages and bring our idea to life. The NGO will also engage a full-time project manager to ensure that the facilitators are well supported. The Americares Nepal country team will manage the program and ensure that technical support, monitoring and evaluation and resource alignment are in place through one of our experienced program managers who will provide approximately 30% time. Americares Headquarters will provide leadership and technical guidance. The Institute for Reproductive Health (IRH) will provide technical support for the creative application of human centered design, interactive activities for beneficiaries and evaluation of the idea.

Using a human-centered design approach, you may uncover insights that lead to small or foundational changes to your organization’s existing strategy or processes in order to unlock the potential of your idea. How would your organization go about making such changes?

Americares uses a project management cycle that includes reflecting on process and outcomes followed by making changes to accommodate findings and changing circumstances. The Americares Nepal team will review implementation experience with the implementing NGO and, as needed, will adapt the idea and reflect again. Americares HQ and the IRH teams will coach the reflective process in support of decision-making. Through coaching from Amplify on human centered design, we expect that the design will have an iterative nature and evolve over time.

What challenges do your end-users face? (1) What is the biggest challenge that your end-users face on a day-to-day, individual level? (2) What is the biggest systems-level challenge that affects your end-users?

Day-to-day, our adolescent girls function within the confines of cultural mores. They also struggle with lack of segregated toilets at schools, no waste bins for disposing sanitary pads at school, and stigma related to accessing family planning and reproductive health services. Photos attached above show girls in Betali village playing the menstruation game. Systemically, tradition and limited resources affect daily life. Girls are not taught about menstruation before it happens to them, and when it does, they are banished from their home and treated as unclean. Our health workers struggle with lack of physical space to have private counseling sessions. Local leaders are gate keepers to change. See photos attached of local leadership.

Tell us about your vision for this project: (1) share one sentence about the impact you would like to see from this project in five years and (2) what is the biggest question you need to answer to get there?

Goal: By 2022, we will aim to make our model available throughout Ramechhap District, reaching all 54 wards and making the model accessible to 50,000 adolescents. Question: How do we maintain the fidelity of the facilitative design and interpersonal communication intensity at scale across distance, difficult terrain and with many teams?

What is it that most attracted you to Amplify instead of a more traditional funding model?

We were looking for an opportunity to better leverage our psychosocial support experience to make ASRH services compelling to youth. We feel that Amplify’s approach is an improvement over the “build it and they will come” approach that is more common. Amplify’s approach to human centered design is refreshing because even though we don’t know all the answers yet, we are committed to ensuring that the realities of our end users and their voices are incorporated into the design of our activities.

Do you intend to implement your Amplify idea in refugee camps / temporary settlements?

  • We aim to implement our Amplify idea in support of displaced populations, but not in a refugee camp / temporary settlement.

How long have you and your colleagues been working on this idea together?

  • Less than 6 months

How many of your organizations’s paid, full-time staff are currently based in the location where the beneficiaries of your proposed idea live?

  • Between 5-10 paid, full-time staff

Is your organization registered in the country you intend to implement your idea in?

  • We are registered in all countries where we plan to implement.

My organization's operational budget for 2016 was:

  • Above $1,000,000 USD

What do you need the most support with for your innovation?

  • Program/Service Design

6 comments

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Spam
Photo of Ashley Tillman
Team

Hi Karl, great to have you in the Challenge! Was very interested to hear about the user research you are planning to conduct would love to hear a little more about your current thoughts around how to best approach youth engagement in your work. Looking forward to learning more!

Spam
Photo of Karl null
Team

Thanks for the note Ashley! We’re really excited about this opportunity.

With our partner, IRH, we understand that traditional research methods don’t often work well with adolescents, particularly younger adolescents (12 – 17 years). IRH has developed methods which enable children’s active participation, thus shifting the balance of power from researcher to participant. These methods have been used in multiple countries to gain insight into young people’s perceptions of gender, equality, puberty and future aspirations. Participatory methods including games, projective drawing, photo-voice, and interactive pile sorts can be made fun, non-threatening, and rigorous. In particular, some techniques were designed to tap into underlying motivations by providing relevant stimuli onto which youth project their feelings. These methods are particularly useful when respondents have contradictory attitudes, are reluctant to discuss sensitive topics, or unable to articulate responses.

A great example of IRH’s work on this topic can be seen in the evaluation of the CHOICES curriculum (1), which was used with 600 Nepali boys and girls, the My Changing Body curriculum in Rwanda (2) and Guatemala (3), and more recently, the GREAT project (4).
Additionally, the staff from both teams are well versed in the protection of children, meeting international ethical standards necessary to conduct research with adolescents.

(1) http://irh.org/wp-content/uploads/2013/04/CHOICES_8.5x11_web_0.pdf
(2) http://irh.org/wp-content/uploads/2013/04/VYA_Rwanda_Brief_8.5x11_2013.pdf
(3) http://irh.org/wp-content/uploads/2013/04/VYA_Guatemala_Brief_8.5x11_2013.pdf
(4) http://irh.org/projects/great_project/

Spam
Photo of Ashley Tillman
Team

Hi Karl, thank you so much for sharing! One last quick question, what do you hope to accomplish year one in this project?

Spam
Photo of Karl null
Team

Hi Ashley-

Our first project year accomplishments will include:

• Completion of a baseline for target behaviors. We will systematically select groups of boys and girls from different ethnic groups, and married/unmarried girls to participate in data collection activities (i.e., projective drawings, pile sorts, etc.) as well as brief focus groups. This will establish a baseline of experience and perceptions of local ASRH services and needs across the contexts of various ethnic groups.

• Further input gathered from each of our target groups will inform the communication and facilitation methods to be for used for our interventions.

• Baselines will be gathered from influencers of each target group such as parents and community leaders, as well as for the Health Post health workers and the female community health volunteers (FCHV). This information will further inform the content and approaches for activities designed for them.

• We expect to have developed facilitation guides for each intervention activity for the adolescents, and to have trained the facilitators from our partner NGO. Other activities will be underway, including the identification of the diversity of adolescents in each community, and the formation of the peer groups.

• ASRH orientation materials for a) health post workers and the FCHVs; b) community leaders; c) parents, will be drafted, field-tested and in use.

• By the end of year one, we will have identified some successful approaches to better address ASRH needs through utilizing similar data collection activities at strategic points across implementation phases. Our aim is to see improvements in ASRH knowledge and attitudes as well as increased interaction with trusted adults and service providers.

Please let me know if you have any other questions, thank you!

-Karl

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