Elements of Successful Family Planning

Interview with Ed Scholl Conducted by Rose Reis and Heather Sanders on April 29, 2008

Rose Reis: Can you tell me, in a demographic sense, where young people are concentrated in the world?

Ed Scholl: Young people ages 10 to 24 make up about a quarter of the world’s population. They are approximately 1.7 billion currently. They are found predominantly in developing countries, where about 30% of population is made up of young people. In developed countries, it’s about 20%. So, overall it’s about 24%, one-quarter. It’s growing: in developing countries, the proportion of the population that is young, and it’s diminishing in developed countries. That puts additional constraints on the developing countries’ economies and the needs for schools, for jobs, for healthcare and social services.

RR: Given all other client needs and resources, why should FP programmers invest in adolescent health services?

ES: The reason why it is so important to invest in health services for young people are: first of all, their needs are very great, they are very vulnerable and the consequences of not providing those services are very costly. They have high levels of unwanted pregnancies and when they do have an unwanted pregnancy, it’s often a very risky pregnancy. The maternal mortality ratio for women 15-19 is about twice as high as those aged 20-24, and about 3 times as high for those under 15. In addition, the potential impact or pay-off is much greater. Imagine reaching a 17 year old woman who is sexual active and in need of FP services. If you provide those services, she’s much more likely to use those services throughout her lifetime. You may have 30 years of protection, whereas if you wait until a woman is 39 and has had all the children that she wants, (although important in its own right) you may have only 10 or fewer years of protection. Because of their vulnerability, because of the risk for maternal mortality, unwanted pregnancy and because of the impact and pay-off, I think it’s really important for program to invest in young people’s health and education and social services.

RR: It’s almost like a business investing in potential clients. That’s a great concept, I have never thought of that.

ES: And besides the impact on maternal mortality, an unintended pregnancy for an adolescent girl is also a time of crisis and it can be a life changing event. It could mean dropping out of school, having to forego potential employment and having to stay at home to take care of an infant. So it’s really a very life-changing event. An unintended pregnancy for any woman is a time of crisis, but it’s all the more compounded for an adolescent girl.

RR: What is the best way to generate demand, in a business sense or programmatic services?

ES: In terms of how to generate demand for family planning services among young people, I think first of all we need to be clear that what we’re trying to achieve are healthy behaviors among young people. For a lot of adolescents, especially for those that are not yet sexually active, that will mean helping delay sexual activity, to learn about sexuality and reproductive health and contraception for the future when they will need it. For those who are sexually active, we need to provide the services that they need, in a way that is acceptable and accessible to them. Young people often do not come to health services. So, in contrast to older women who are often accessing services to bring their children in for immunization or anything, young people tend to no go to clinics. Therefore it is a challenge to get services to them. Sometimes you have to think outside of the health facility box and think of where you can go to provide health services. It might be a youth center, it often means making sure condoms and oral contraceptives in pharmacies are accessible, that they are affordable (because that’s where young people tend to go especially for condoms, which is the most condom method used by young people). Looking to commercial establishments, looking to places outside of health facilities establishments, as well as health facilities themselves, making sure they are youth-friendly is really important.

RR: Do you think that the method-mix is ideal for young people?

ES: Currently, condoms are the most popular methods for HIV prevention and pregnancy prevention as well, especially among unmarried youth. Many married couples will use oral contraceptives and increasingly injectables. I don’t think there’s an ideal method-mix. I guess it’s ideal if there’s dual protection, against pregnancy and HIV. Commonly, that is thought of as condoms and another method. There’s no one ideal method for pregnancy prevention. And I think we need to get away from the idea that it can only be condoms and pills, because injectables can be used and IUDs and other methods (implants) can be used as well. It depends on characteristics and life-situation of the young person.

RR: Do providers treat adolescents differently as clients?

ES: There are some real challenges providing family planning services to young people, both on the supply and the demand side. On the demand side, there is the challenge of getting information and education out. The media does a pretty good job of mis-information out there, promoting sexuality without the three C’s: without commitment, without showing consequences, and without condoms. There is a lot of information in the media about sexuality but not much good factual information. So that needs to be provided in schools, through parents and through health providers to increase demand and use of family planning methods and healthy behaviors. Besides the demand side, on the supply side the challenges are providing youth-friendly services, attractive and accessible to young people, having hours that are convenient, having confidential services where young people don’t fear their parents being told if they want to keep it a secret, making sure that providers are nonjudgmental and treat them with respect, and having prices that are affordable. Providers can often times project their own barriers, not only the judgmental part, but sometimes they have erroneous beliefs about certain methods not being appropriate for young people (e.g. you have to be a certain age to use a hormonal method). So, it’s important to educate providers about what are appropriate and inappropriate criteria for providing methods, and there are no methods are automatically excluded simply because of age, but rather based on the situation of each client.

RR: Is integrating HIV/AID VCT with family planning more important with youth populations?

ES: Integrating family planning into HIV counseling and testing services is important for everyone, but it’s especially important for young people because young people tend to be exposed and vulnerable to both. They don’t separate those concerns out in their mind; they fear both, they have vulnerability to both and they should have services that address both of those needs. For example, a place where you can go for counseling and testing, it makes a great deal of sense to have that provider be trained in assessing family planning risk as well as STI risks and being able to provide counseling and information about family planning, and generally referring for those services. It would be great if they could actually have condoms, or pills and injectables if their trained to have those on hand, but at a minimum refer elsewhere for those services. They should be doing a screening for risk of pregnancy and some minimal counseling.

RR: What other services should be offered through programs targeting youth?

ES: Besides HIV counseling and testing, it’s also important to provide HIV follow-up for those who are positive, provide care and treatment, provide screening and treatment for STIs and of course all the therapies that surround pregnancy and birth. After all, more than half of women in sub-Saharan Africa have already given birth by the time they’re 20, so when we talk about women and the services they need, pre-natal care, safe pregnancy and post-natal care are vitally important as well as services for their newborns. Besides those health services, many programs offer non-health-related services, like literacy and education services, vocational training and even recreational services that are important in their own right and also have an impact of young people’s reproductive health as well.

RR: Do you think that programs should offer these programs?

ES: Whether or not a program offers all these services in addition to family planning is going to depend on the program, the country, the target population. Many programs will have a more vertical approach and offer family planning services while referring for other services. To the extent possible, you want to offer as many services as you can, as your budget can accommodate, as your staffing can accommodate under one roof, as possible and then refer to other youth services. that you cannot provide directly. That’s a goal that each program has to look at what it can provide. Sometimes there are in-house referrals, you can provide family planning in one room and refer to other services down the hall.

RR: Should programs incorporate systematic screening to increase FP use in youth population? And if so what kinds of job aides and tools can providers use?

ES: I think systematic screening is a great methodology for increasing the use of services, especially under-utilized services. Too often, providers ask what you have come for; if it’s a VCT clinic it’s for HIV testing. But that doesn’t mean that they don’t have other needs. Need to prevent pregnancy, maybe an STI, maybe they’re pregnant and need pre-natal care. There are lots of potential needs a person has and it’s much better to try to screen for those and provide them or to refer for them, than to wait for the patient to return for them. There are some great tools available. The Population Council has developed one called Systematic Screening. It starts out with a simple question of, rather than asking why the patient has come, at some point during the interview you ask, “Are you pregnant?” and if not, “Are you using a method of family planning?” and if not, “Would you like to? Can I give you some information about it?” So you ask this series of question and respond accordingly to the client’s wishes.

ES: The name of the tool I was referring to was Introducing Systematic Screening to Reduce Unmet Health Needs. It was developed by the Population Council. I was actually working in Guatemala with USAID before joining FHI and the Frontiers project tested the tool there, among Mayan women and other women in Peru. It proved to be very effective in assuring that clients were given additional services they were needing and it increased the uptake of family planning.

RR: Can you talk about the program in Guatemala and how this program was tailored to meet the needs of the population?

ES: In Guatemala I had the opportunity to work with USAID and a variety of partners on family planning and child survival interventions, targeting the rural indigenous population. What I came away with was a renewed appreciation for, first of all the challenges of working with indigenous populations, but also real appreciation for the groups that were working, the Ministry of Health, APROFAM (the affiliate) and many indigenous NGOs that were working with that population and doing wonderful things. They all had different approaches that were complimentary. APROFAM had a series of clinics throughout the country and community-based distribution workers, many of whom were indigenous themselves (both men and women). The Ministry of Health of course had its network of hospitals and clinics throughout the country, and a lot of these small indigenous NGOs did house to house promotion and education and provision of maternal/child health as well as family planning services. I think some lessons learned for me was: One, it’s important to have connections in the community to use promoters from that community, who speak the local languages to be your family planning promoters.

Secondly, to have linkages to clinics because a lot of women do want IUDs or sterilization or methods that they can’t receive in the community; and of course they want access to safe obstetric care that they can only get in the clinics (although many also deliver at home).

Third, they also need access to affordable services located near their home. One innovative program actually took providers out to rural areas to provide clinical methods (like IUD insertion and female sterilization). They set up shop in schools or community centers in the village. It wasn’t an operating theater, but it was as clean as they could get. And they actually provided those services there outside the walls of a health facility. I though it was very innovative and provided clinical services to a lot of women that would have never traveled by bus for an entire day to get to a Ministry of Health or APROFAM clinic.

RR: Were the services provided reduced in cost?

ES: The cost had to be very low, although it was never free, except in some rare situations. Usually, there was nominal costs for family planning services and maternal/child health services. The Ministry of Health did provide it for free, but through the NGOs and APROFAM, there was a cost. At least with the case of APROFAM, they were able to subsidize; they earned a profit through a lot of the services they provided in Guatemala City and other cities, including lab services, selling of medicines and even rather complex services like bone density scanning and ultrasounds (These were services provided to more middle-class women and they made money off of that, and then used to cross-subsidize their rural outreach programs to the Mayan women).

Heather Sanders: Do you have any examples of programs that have been successful outside of the health clinic that was able to access youth?

ES: I mentioned that a lot of times you can’t easily find youth inside a health facility, so you need to take services outside the health facility where young people are. To give you an example of that, in Tanzania, the YouthNet Project I worked on previously, we worked with sports clubs (soccer teams in particular). We worked with coaches and captains to provide them with information about HIV that they in turn shared with the team members. At half time or during the game, a practice session, they might have a time to learn about HIV and how to prevent HIV in context of being a healthy sportsman; and to be a healthy sportsman you have to keep yourself free from HIV.

Another example of reaching youth outside clinic walls, there are many many countries that use peer educators. That is probably one of the most popular ways of reaching youth outside of the clinic without using schools with adult teachers, peer educators is a very common approach. Of ten times the peer educators themselves are the most impacted by the messages and change their behaviors. They don’t always start as the ideal models but through their own life experiences they can readily identify with the peers they’re trying to reach. It’s also very important to have a linkage with adults in peer education programs and with adult-led facilities and services. But often a good entry point to reach youth is peer educators.

Another way to reach young people with information that can lead to services and can also begin to change social norms and give opportunity for young people to talk about difficult subjects is the media. The YouthNet Project had a partnership with MTV International, and they had an HIV awareness campaign called “Staying Alive”. They had concerts, PSA, testimonials from famous people, interviews with Nelson Mandela, talking about HIV prevention and it was heard by young people all around the world, and not just upper young people, with access to cable television. The program went much deeper than reaching just that group and reached lots of lower-income youth. That is one model.

Another model is using local media, local radio stations in particular. There’s a youth-run radio program in Paraguay that I visited and they talked about all kinds of subjects relating to pregnancy-prevention and STIs and HIV. There was also a television program ran in Nicaragua, that became one of the highest rating television programs in Nicaragua, all about young people and their sexual reproductive health and situations, choices, decisions, problems that they faced. Media definitely has a big role to play. It’s hard to show causation between a media message and behavior change, but often media is the first step in the chain that leads to behavior change. It can create an opportunity for parents to talk to children about something they heard on TV that will demystify taboo subjects. It’s definitely important but needs to be followed up by interpersonal communication.