Young People and Contraceptive Access - An advocacy and communications toolkit

Publication date: 2018

Young People and Contraceptive Access An advocacy and communications toolkit OCTOBER 2017 1YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Contents The Youth Caucus Key Messages encapsulate 18 recommendations that tackle the barriers young people face and focus on the lack of age-appropriate information, transportation issues, misconceptions, lack of trust in the decision-making and independence of young people, etc. This handbook will explain how to best use the key messages, to advocate adolescents’ access to reproductive health supplies, communicate online about reproductive health topics and explain why young people need a specific focus. BACKGROUND THE KEY MESSAGES WHY A TOOLKIT? p.3 This section explains how the RHSC came to add a youth-centred focus to its range of activities, how the key messages handbook came to be, and how to use it. THE YOUTH CAUCUS KEY MESSAGES p.10 This is a set of 18 recommendations to ensure universal access to high quality and affordable contraceptive supplies for young people based on their needs. These recommendations have been developed based on the RHSC’s vision and different youth consultations that identified adolescents’ needs. WHY ARE YOUNG PEOPLE A SPECIAL CASE? p.4 Asking organizations to add a youth-centred approach to reproductive health supplies access requires explaining why that is important. This section explores the barriers young people face when trying to access reproductive health supplies; it demonstrates how these barriers are bigger for young people compared to the rest of the world. YOUNG PEOPLE AND THE REPRODUCTIVE HEALTH SUPPLIES COALITION p8 The Reproductive Health Supplies Coalition’s (RHSC’s) Youth Caucus Key Messages are in line with the general vision and strategy of the RHSC and its four pillars: Availability, Quality, Equity and Choice. This section links those four pillars to clear demands regarding young people and reproductive health supplies. 2YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS ENGAGING ONLINE: BEST-PRACTICES AND TIPS & TRICKS STAY IN TOUCH! ANNEX AND BIBLIOGRAPHY THE TOOLS p.12 This set of tools contains guidelines to help start up advocacy around the key messages in your country, region, or on the international political level. By going through seven steps you will have a clearer understanding about how to use the key messages in the most effective way. ENGAGING ONLINE p.20 Modern day technology allows reproductive health advocates to empower and reach adolescents using innovative applications, interactive websites or by using the internet to provide user-tailored information. This section off the handbook gives an overview of best practices and innovative ways of improving adolescents’ access to reproductive health services, supplies and information about their needs. We give you tips and tricks to improve the efficiency and quality of online advocating and communicating about sexual and reproductive health. KEEP US INFORMED p.31 As the RHSC we are interested to hear about the advocacy work you have done around the key messages and would be happy to include any suggestions or recommendations in our future work. BIBLIOGRAPHY p.32 Overview of all the publications referred to in the key messages handbook. 3YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT BACKGROUND Why a Toolkit? At the Reproductive Health Supplies Coalition’s (RHSC’s) 2015 General Membership Meeting (GMM) in Oslo, young advocates pointed out that a genuine focus on youth was missing in the Coalition’s work. Members welcomed this call for more emphasis on young people’s access to reproductive health (RH) supplies. A Youth Discussion Group was formed, providing a platform for young members and youth experts to share knowledge, identify gaps, and plan collaborative work to increase young people’s access to contraceptives. The group’s work led to a significant youth presence at the following GMM in Seattle in 2016. In May 2017, the Coalition’s Executive Committee approved the establishment of the Youth Caucus, giving the group a mandate to strengthen young people’s engagement and participation within the Coalition and to increase data on young people’s RH supply needs. As a first response, the Youth Caucus developed The RHSC Youth Caucus Key Messages on Young People’s RH Supplies Access. This document is a powerful call to action, asking governments, CSOs, research institutions, the private sector, and the international community to address young people’s RH supply needs in a number of specific ways. RHSC YOUTH CAUCUS KEY MESSAGES ON YOUNG PEOPLE’S RH SUPPLIES ACCESS The publication can be downloaded from the rhsupplies.org website: http://bit.ly/2g4jpyT 4YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Why are young people a “special case”? Young women face a significantly higher burden of unmet need for contraception than older women do. A Guttmacher report on 31 developing countries indicates that women between the age of 15 and 24 years face an unmet need of 31 percent compared to only 23 percent when women are between 24 and 49 years old (2006–2014)1 (Gilda Sedgh, 2016). Unmet need for contraception is related to both providers and users and both present obstacles for youth. Supply side barriers Age-based restrictions There are two main types of age-based restrictions that limit the access of young people to RH supplies, legal restrictions and societal restrictions. Among legal restrictions, the two main sets of laws that form a barrier for adolescents’ are parental consent laws and the age of consent for sexual intercourse. In 2012, the European Court of Human Rights issued a landmark decision on parental consent in a case concerning Poland’s strict abortion law. The court noted that “legal guardianship cannot be considered to automatically confer on the parents of a minor, the right to take decisions concerning the minor’s reproductive choices, because proper regard must be had to the minor’s personal autonomy in this sphere.” However, in many countries adolescents still require parental consent when accessing RH services. This has a negative effect because minors will not seek services if they are forced to involve their parents. Parental consent laws apply to a wide range of topics regarding Sexual and Reproductive health like legal abortion, Sexual Transmitted Infection (STI) testing and contraceptive services. The age of consent for sexual intercourse varies from 11 to 21 years old across the world. There are countries without a legal age of consent, but all sexual relations are forbidden outside of marriage. In other countries, there is a ‘close in age exemption’ to decriminalize consensual sex between to individuals who are both under the age of consent. Having a high age of consent can severely limits the access of adolescent’s to RH services. If sexual intercourse is an illegal BACKGROUND from Abuja (23%) and Ibadan (22%). The largest proportion of the PMV sample was from Benin City (20%) and the smallest was from Ilorin (14%). The majority of health facility providers (60%) had no in-service family plan- ning training experience while 42% of pharmacists and 45% of PMV operators had family planning training experience (see Table 1). Health facility providers, pharmacists, and PMV opera- tors reported restricting access to family planning methods based on demographic factors (see Table 2). Minimum age restrictions ranged between 70 and 93% across method and provider type. Restrictions based on minimum age were high for all methods and types of providers but were relatively lower for provision of condoms, EC, and pills (70–87%), and highest for injectables and IUDs from (84 to 93%). Health facility providers were less likely to have a minimum age bias for EC (70%) than pharmacists or PMVs (75–83%). In contrast, health facility providers had greater minimum age bias for pills (87%) than did pharmacists or PMVs (80–82%). Minimum parity restrictions ranged between 3 and 65% across method and provider type. Restrictions based on minimum parity were lowest for provision of condoms (3–6%) followed by EC (12–20%). Among pharmacists only, pill use (29%) was more likely to be restricted by parity than injectable use (22%). Among health facility providers, injectables were the most likely to be restricted (65%) by parity - even more so than IUDs (53%). Nearly half of PMV operators (44%) indicated they restrict access to pills based upon parity compared to fewer pharmacists and health facility providers (29–38%). Injectable use was three times more likely to be restricted based upon parity among health facility providers (65%) than phar- macists (22%). Marital status restrictions ranged between 7 and 74% across method and provider type. Restrictions based on marital status were lowest for provision of condoms (7– 10%) and EC (17–26%), and highest for IUDs (67%) and injectables (45–73%). Nearly half of all provider types re- strict access to pills based upon marital status (42–58%). As with minimum parity, health facility providers were more likely to restrict access to injectables (74%) than IUDs (67%) and were much more likely than pharma- cists (45%) to restrict access based upon marital status. For all health providers, minimum age bias was the most common bias while a minimum parity was the least common bias. Condoms consistently had the low- est overall bias score, followed by EC, pills, IUD, and in- jectables. Pharmacists had the overall bias score for both pills and injectables (1.5). Health facility providers had a higher bias towards injectables (2.3) as compared to IUDs (2.1). Health facility providers have a higher bias score for injectables (2.3) when compared to pharmacists (1.5). When comparing overall bias scores by method and provider type, PMV providers have the highest over- all bias score for condoms, pills, and injectables com- bined (3.8) and pharmacists have the lowest (3.6) (see Table 2). Provider biases in service provision were examined by experience of in-service family planning training and type of provider (see Table 3). Experience of in-service training was associated with a lower prevalence of mari- tal status service provision biases for pill, injectable, and IUD methods among nurses/midwives and CHEWs. Training also affected the minimum parity bias for in- jectable provision among nurses/midwives as well as pill provision among CHEWs. The effect of training was in the opposite direction than expected for pill and inject- able minimum age bias for both nurse/midwives and CHEWs. The overall bias score was lower for providers who received in-service training for pill, injectable, and Table 2 Health facility, Pharmacy, and PMV family planning providers’ prevalence of restriction of clients’ access to contraceptive methods by restriction and method, Nigeria 2010 Health facility providers Pharmacists PMV Operators Minimum age n % n % n % Male condom 692 73.1 410 76.3 474 70.7 Pill 906 86.9** 318 81.8 313 79.9 EC 395 70.1*** 292 82.9 183 75.4 Injectable 1071 88.5* 289 84.1 na na IUD 560 93.2 na na na na Minimum parity Male condom 692 3.0* 410 2.9 474 5.7 Pill 906 38.3*** 318 28.9 313 43.5 EC 395 12.7* 292 12.3 183 20.2 Injectable 1071 64.7*** 289 21.8 na na IUD 560 53.4 na na na na Marital status Male condom 692 10.4 410 9.5 474 7.2 Pill 906 51.3*** 318 41.5 313 57.5 EC 395 16.7** 292 26.4 183 23.5 Injectable 1071 73.5*** 289 45.3 na na IUD 560 67.3 na na na na Overall bias score Male condom 692 0.9 410 0.9 474 0.8 Pill 906 1.8*** 318 1.5 313 1.8 EC 395 1.0*** 292 1.2 183 1.2 Injectable 1071 2.3*** 289 1.5 na na IUD 560 2.1 na na na na Totala 3.7 3.6 3.8 na Not applicable *p ≤ 0.05; **p ≤0.01; ***p ≤ 0.001; Chi Square, Anova, and t-tests of the association between bias and provider type anot including injectable or IUD Schwandt et al. BMC Health Services Research (2017) 17:268 Page 4 of 9 1. https://www.guttmacher.org/sites/default/files/report_downloads/unmet_need_tables_1-15.pdf Source: Schwandt,2017,p.3 5YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT BACKGROUND activity, accessing related services (like contraceptives services or abortion care) is not an easy undertaking. Even when accessing contraceptive commodities is legally possible, there are still many barriers keeping adolescents from going to a health centre and receiving the products they desire. Provider bias is main societal restriction on the supplier-side. This means pharmacists, healthcare worker or other providers will not allow young people to purchase contraceptives based on their personal opinion and belief-system. A study (Schwandt, 2017) of six locations in Nigeria showed that the provider imposed eligibility barriers in terms of age, parity and marital status. Age is overall the most recurrent restriction, which is consistent with research in other countries like Kenya (Tumlinson, 2015), Tanzania (Speizer, 2000), Ghana (Stanback, 2001) and India (Calhoun, 2013). Societal myths and ignorance are often the reason for personal restrictions on the supplier side. The result is that young unmarried people do not receive their contraceptive method of choice. Limiting provider bias towards young people requires not just training healthcare workers and pharmacists and providing them with the full range of supplies, but also addressing the lack of community support for adolescents accessing and using contraceptives. Stockouts and service environment Stockouts are linked to the discontinuation of contraceptive use and are cited as a reason for unmet need and high rates of unintended pregnancies in many countries. A 2011 report (DFID Nigeria Human Development Team, 2011) by DFID listed reductions in unintended pregnancy, maternal mortality, and improved health outcomes among both women and children as potential benefits of increased access to the right contraceptives. Several key factors are linked to stockouts including long lead-times for procurement or delivery of products due to bureaucratic and manufacturing processes, insufficient funding for commodities and supply chain operation, lack of supply chain training for health providers and the need to improve supply chain information systems and forecasting of stock needs. Many countries only procure adequate supplies of a few of these methods, in the belief that just a few options are all that people want and that procuring a wider range would be wasteful. This has a negative effect on the correct use of contraceptives as a study suggests that there is more discontinuation when a method is not the user’s first choice. Analyses of Demographic and Health Survey (DHS) data indicate that between 7 and 27 percent of women stop using a contraceptive method for reasons related to commodity stock-outs and the service environment, including service quality, availability of a sufficient choice of methods and ineffective referral mechanisms (Castle S., 2015). Young people have a higher rate of discontinuation (Polis, 2016; Yinger, 2016), something that will be discussed more in depth under user-related barriers. Regarding stock outs and service environment, this may mean young women face more obstacles relating to a lack of access or information, or the social stigma often associated with sexual activity among unmarried adolescents. Product development and tailored marketing Before a new reproductive health product is available in health centres, it goes through a process of clinical trials. A webinar hosted by the RHSC looked at the safety of contraceptives for young people. Generally, young people are not side-lined nor excluded from clinical trials of existing contraceptive methods, but neither do their unique needs inform the development of new contraceptives. So much so that the US National Institutes of Health have begun to request that research be conducted around young people’s SRH needs to inform new contraceptive development. The same can be said for age-appropriate information on RH supplies and the packaging of products. During different youth consultations held by the RHSC Youth Caucus, young people voiced difficulties identifying the quality and correct way to use contraceptive products. An increased visibility of expiration dates and quality marks could contribute to the proper use of contraceptive methods and refute common misconceptions or myths. 2. https://www.rhsupplies.org/uploads/tx_rhscpublications/Youth_consultation_on_reproductive_health_supplies.pdf 3. https://www.rhsupplies.org/uploads/tx_rhscpublications/Second_Youth_consultation_on_reproductive_health_supplies-Indonesia.pdf 6YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT User-related barriers Societal myths and stigma Misconceptions and stigmatization about contraceptive methods have long influenced women and men’s decisions to adopt and continue certain contraceptive methods. A pervasive fear is that modern contraceptive use can lead to infertility. Other common myths are that contraceptives cause cancer or result in short or long term health problems. An analysis (Bellizzi, 2015) performed in 35 countries found that side effects and health concerns were said to be the reason for non-use by 37 percent of the women. Other research (Gueye, 2015) showed that in Kenya, Senegal and Nigeria, women and men believed at least two to four out of the eight myths the study presented. They found this directly affected the rate of contraceptive use in the communities. A higher unmet need for contraception commonly coincided with a higher fear of using contraceptives, resulting in a higher discontinuation rate. Adolescents may face more stigma- related barriers, as premarital sex and sexual activity by adolescents is heavily condemned in many societies. This does not only result in provider bias, but also user-related fear and shame towards contraceptive methods. The results from a study among young women in Kenya follow this line of reasoning (Ochako, 2015).The main barriers identified to modern contraceptive uptake, were myths and misconceptions. These findings stress the influence of social network approval on the use of contraceptives, beyond the individual’s beliefs. BACKGROUND Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript G ueye et al. Page 15 Table 2 Percentage of women and men who agree with selected family planning myths, by country Myth Kenya Nigeria Senegal Women (N=5,684) Men (N=2,477) Women (N=9,130) Men (N=5,041) Women (N=5,109) Men (N=2,244) Use of a contraceptive injection can make a woman permanently infertile 51.7 52.1 41.0 31.2 34.0 31.6 People who use contraceptives end up with health problems 74.1 71.8 47.6 37.7 58.9 50.0 Contraceptives can harm your womb 62.1 na 42.4 na 36.9 44.1 Contraceptives reduce women's sexual urge 59.1 61.2 22.7 25.9 24.7 39.6 Contraceptives can cause cancer 55.5 51.7 25.2 30.1 24.0 26.0 Contraceptives can give you deformed babies 62.0 59.6 26.0 33.7 23.2 24.5 Contraceptives are dangerous to women's health 71.5 68.0 46.6 43.2 50.2 43.8 Women who use family planning/birthspacing may become promiscuous 35.0 40.2 23.0 25.7 na na Family planning/birthspacing is women's business and a man should not have to worry about it na 15.6 na 13.9 na na Mean (range)† 4.6 (0–8) 4.3 (0–8) 2.7 (0–8) 2.5 (0–8) 2.6 (0–7) 2.8 (0–7) † The average number of positive responses among eight (seven in Senegal) family planning myths. Notes: na=not applicable. All percentages are weighted and based on women and men who know at least one modern contraceptive method. Int Perspect Sex R eprod H ealth. A uthor m anuscript; available in P M C 2016 M ay 05. www.prb.org YOUTH AND LONG-ACTING REVERSIBLE CONTRACEPTIVES 4 competent way, youth may be more likely to adopt these methods. The results during an eight-month postintervention period showed this impact clearly: • Young women who received information and counseling on LARCs were more likely to choose LARCs. After the intervention, for every 100 females who adopted LARCs at the nonintervention sites, 130 females adopted LARCs at intervention sites. • New clients were less likely to choose short- acting methods after the intervention. During the postintervention phase, only 93 females in the intervention sites chose short-acting methods for every 100 who chose them at the control sites. These results were especially interesting given that at baseline the sites chosen for the intervention had even fewer women adopting LARCs than at the control sites (70 vs 100). Findings also suggested that a growing number of women who had not yet started childbearing sought contraceptive services and often chose long-acting methods. During the study period, 63 percent of women who attended youth-friendly services had not yet had any children, and 81 percent of women at intervention sites who chose a long-acting method for the first time had no children.14 Overall, the study found that better provider skills and counseling related to LARCs was essential to uptake among young people, while peer counselors did not appear to play a strong role in encouraging young people to use LARCs. Madagascar: Family Planning E-Vouchers Improve Equity and Access to LARCs To address unmet need for family planning among young people, UNFPA partnered with Marie Stopes Madagascar and Sisal to implement an e-voucher program.15 The main objective was to use mobile phone technology to increase access to and use of integrated services—family planning (FP) and STI/HIV— and among the most at-risk youth. The program offered free FP and/ or STI information and payment vouchers through text messages (short-message service or SMS). According to a 2013 survey, one in three adolescent girls under age 18 in Madagascar had already given birth or was pregnant.16 Early childbearing is particularly prevalent among poorer and less-educated girls, highlighting the challenges of inequitable access to sexual reproductive health information and services. Mobile phone services and ownership have grown significantly in recent years, and in focus groups young people recommended using mobile phone services as an effective strategy to disseminate SRHR information. Service providers reported that mobile payment would be an effective incentive to maintain high- quality service delivery. Combining these two trends, Marie Stopes launched a two-year youth initiative in southern Madagascar in 2013. Twelve peer educators provided information to young people, distributed e-vouchers, and referred youth to Marie Stopes and BlueStar clinics.17 Young clients received a code via text to use for free FP services. To ensure services were provided to all young people, peer educators used their own phone to receive an e-voucher FIGURE 2 Youth Who Use Contraceptives Generally Do Not Choose the Most Effective Methods. Method Mix Among Youth and Older Ages 0 20 40 60 80 100 Sterilization, female Sterilization, male Implants IUD Injection Pill Male Condom Traditional methods 45-4940-4435-3930-3425-2920-2415-19 Source: John Ross, Jill Keesbury, and Karen Hardee, “Trends in the Contraceptive Method Mix in Low- and Middle-Income Countries: Analysis Using a New ‘Average Deviation’’’ Measure,” Global Health Science and Practice 3, no. 1 (2015): 34-55. Source: Gueye, 2015, p.15 Source: Ross, J. K. 2015, p.41 7YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Contraceptive failure rates According to recent studies (Polis, 2016), of the 74 million unintended pregnancies that occur annually in the developing world, 30 percent are due to contraceptive failure among women using some type of contraceptive method. This includes method-related failures (i.e., failure of a method to work) as well as user-related failures (i.e., failure due to incorrect or inconsistent use). Compared with adults, adolescent contraceptive behavior is characterized by shorter periods of consistent use, higher contraceptive use-failure rates, and greater likelihood of stopping for reasons other than the desire to become pregnant (Castle S., 2015). One study (Blanc, 2009) concluded that on average, contraceptive failure rates where 25 percent higher among 15-19 old girls compared to women aged 20-49. When comparing the intermediate effects of age, wealth, education and place of living, age was by far the strongest influence on the effective use of contraceptive methods. This shows that young people can benefit from age-appropriate counseling and increased Comprehensive Sexual Education (CSE) that promote a full range of contraceptive methods, including Long-Acting Reversible Contraceptives (LARCs). LARCs not only have the lowest failure rates, they are also the only method where there is no difference in failure rates between adolescents and older women. But as indicated by the contraceptive method-mix, the use of LARCs is much lower among adolescents. The use of LARCs among adolescents To reduce unmet need, young people require access to a wide range of contraceptives, including LARCs, which have a less than 1 percent failure rate. The use of LARCs among young women however is much lower than among women of age (Ross, 2015). A cross-country study (Yinger, 2016; Simon, 2016) conducted in Tanzania, Niger, Mozambique, Bangladesh and Ethiopia found many reasons for the low prevalence of LARCs among young people: › Providers refuse to offer LARCs because clients were too young, had not had a child, or are unmarried. › Social norms and stigma around the use of LARCs, that prevented adolescents and youth from choosing the method of contraception they want to use. › Significant policy barriers and legal restrictions. For example, in Bangladesh, newly married couples could get an implant, but young women had to have a child to get an IUD. A lack of CSE limits adolescents’ ability to make informed decisions around contraceptive use as they do not know of LARCs or are influenced by myths. Ensuring the rights of young people to access and use all contraceptive methods has the potential to reduce unintended pregnancies. This in turn leads to fewer unsafe abortions and maternal deaths. The key messages provide clear asks and action points to accomplish the inclusion of young people in the Coalition’s work as well as advocate for political and financial support at the national and international level. BACKGROUND 5 YOUTH AND LONG-ACTING REVERSIBLE CONTRACEPTIVES www.prb.org code that they gave to clients who did not have a mobile phone. The BlueStar clinics in turn used the same text codes to claim reimbursement from Marie Stopes via mobile money. This system built on Marie Stopes’ extensive experience with text-based reporting which was established for the BlueStar clinic network. Marie Stopes negotiated with mobile phone companies to get fair prices for text messaging services. Peer educators and providers were trained on the e-voucher process, on working with youth, counseling, and use of mobile phones to ask for an e-voucher code, and were provided with regular follow-up through refresher training and supportive supervision. Data collected over 18 months highlight that this creative approach supported many young women to receive services they might not have known about or been able to otherwise afford: • Number of young women who were given e-vouchers for free services: 2,714. • Number of young women who used the services: approximately 2,000. • Number of LARCs provided: 1,595. • Unintended pregnancies avoided: 1,900. Overall, the use of mobile phones and mobile money effectively expanded youth access to FP services, improved project management by providing real-time data (service provision and redemption), and increased financial and administrative efficiency by reducing travel, paperwork, and risks associated with cash transfers.18 Recommended Actions Policymakers and donors can support ongoing efforts to expand and improve youth SRHR and increase the use of LARCs through several key actions: Sign on to support and implement the Global Consensus Statement on youth and LARCs. Countries and organizations committed to the FP2020 process—to provide contraceptives to 120 million new users by 2020—can help achieve this goal by assessing the needs of youth and building their access to full and voluntary choice of the most effective contraceptive methods. The examples from Ethiopia and Madagascar highlight that creative strategies can be employed to ensure youth have access to a full range of contraceptive methods, including LARCs, in the context of youth-friendly services. Ensure that providers have adequate technical and counseling skills to support expanded LARC services. LARCs are provider-dependent methods. Providers must have up-to-date guidance on their technical features, especially in regards to how they counsel youth and facilitate their method choice. Providers need to be nonjudgmental about sexual activity among unmarried clients as well as regarding the desire to postpone first pregnancy or space pregnancies among those newly married. Providers need to listen better to client’s fertility goals and provide full information on all methods, which may require changing the way they present options. For example, if a young woman clearly states that she wants to avoid pregnancy so that she can complete schooling, then LARCs can be a good first option. However, it is also critical to be more intentional in addressing side effects of LARCs, such as changes in menstrual bleeding, so that potential users will FIGURE 3 Young Women Do Not Use Contraceptive Methods as Effectively as Older Women. Twelve-Month Failure Rates, by Age (pooled estimates) 0 5 10 15 20 25 Implant IUD Injectable Pill Male Condom Withdrawal Periodic Abstinence Probabilities per 100 Episodes Age <25 Age >_ 25 Source: Chelsea B. Polis et al., Contraceptive Failure Rates in the Developing World: An Analysis of Demographic and Health Survey Data in 43 Countries (New York: Guttmacher Institute, 2016). Source: Polis, C. B. 2016, p.30 8YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT BACKGROUND Young People and the Coalition How can the work of the Youth Caucus be linked to the Coalition’s Strategic Pillars? The Youth Caucus Key Messages encapsulate 18 recommendations that tackle the barriers young people face and focus on the lack of age-appropriate information, transportation issues, misconceptions, lack of trust in the decision-making and independence of young people, etc. Filling this gap is a crucial step towards reaching the health equity and universal health coverage goals of the Sustainable Development Goals and the mission statement of the coalition: ‘To ensure that all people are able to access and use affordable, quality supplies, including a broad choice of contraceptive methods, needed to ensure their better sexual and reproductive health.’ The RHSC Youth Caucus Key Messages are in line with the general vision and strategy of the RHSC and its four pillars: Availability, Quality, Equity and Choice. Today the Youth Caucus includes 140 members from more than 76 organizations, 38 of which are based in low-income countries. Just like all the other implementing mechanisms, the Youth Caucus comprises experts, in this case on RH Supplies and young people. The work of the Youth Caucus fits well under the RHSC pillars as well as the its levers of change (Neutrality, Convening Power, Brain Trust, Brokering Partnerships, Flexible Resource Base and our Respected Name). To date, the youth-related SRHR discussions have focused on the importance of youth-friendly services but have often overlooked actual access to reproductive health supplies. By informing more young people about supply chain management, market development, and making supplies part of national and international youth SRHR discussions, RHSC will promote a positive environment for policy change. Young people’s insights and guidance on youth-specific supply chain needs can only stand to strengthen the Coalition’s reach and expertise. In addition, young reproductive health ambassadors hold the potential to recognize the importance of supply-related positions; raise the profile of supply chain managers; and disseminate proven strategies to enhance supply chain performance in the course of their future careers. This is why the key messages bring attention to: › Youth-specific distribution channels › Working with private sector as a primary access point › Preventing stockouts of youth preferred methods AVAILABILITY 9YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT BACKGROUND Young people are most likely to receive low-quality reproductive health products because they often lack information, have fewer points-of-access welcoming them, struggle against societal taboo, and are more likely to fall prey to unethical marketing practices4. The Coalition cannot only commit to ensuring that high quality products are available; it can also help to make sure young consumers can recognize and ask for quality. When young users demand quality, they will also demand accountability and standards from manufacturers. To build capacity among young people to recognize the difference between a high quality and low quality RH product, the key messages recommend investing in: › Branding and marketing with young people in mind › Building youth feedback into packaging, making product information accessible through technology and education › Providing youth-tailored counselling approaches Age can profoundly affect an individual’s ability to access reproductive health supplies because it influences attitudes, service providers’ bias, ability to pay for products and the needs of the consumer and it brings along legal requirements for parental consent. To encourage governments to embrace and uphold the principle of equity, and ensure full access to contraceptives for young people, the Youth Caucus developed these specific messages jointly with young people to advocate for change and the necessary resources and strategies to bring that change about. The Coalition’s neutral space makes sure that product designs and product delivery systems take into account the different barriers faced by young people. To give young people equity, it is necessary to focus especially on youth-specific barriers: › Age-based and consent restrictions › High costs for some youth preferred methods › Stigma surrounding premarital sex and provider bias towards young people The need for reproductive health supplies evolves throughout an individual’s life cycle. Young people often have specific needs but generally do not use the contraceptive method that is most suited for their situation5. In the case of contraceptives, individuals should have access to multiple options including long- and short-term methods as well as hormonal and non-hormonal contraceptives. The specific contraceptive needs of young people represent a relatively little-known area that lacks clear and consistent data; notions of safety dictate the provision of supplies to young people, and preference does not figure prominently. The Youth Caucus has taken this issue head-on with reports with consultations and webinars to begin to chip away at these entrenched attitudes. The Coalition stands as the community’s brain trust and convening power on youth-related supplies issues. To improve young people’s ability to choose, invest in: › Age-appropriate information on SRH methods › A range of supplies for young people to include stigmatized methods, like Long-Acting Reversible Contraceptives › Setting or disseminating existing standards and organising trainings for service providers to better understand young people’s needs QUALITY EQUITY CHOICE 4. https://www.rhsupplies.org/uploads/tx_rhscpublications/Youth_consultation_on_reproductive_health_supplies.pdf 5. http://www.prb.org/pdf16/pace-policy-brief-larcs-2016.pdf 10YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE KEY MESSAGES The Key Messages The following key messages have been formulated by the RHSC Youth Caucus. They can be used to advocate for political and financial support at national (local, in country) and international level for young people to acquire accurate information (and life skills) around sexual and (SRHR) and rights supporting them to access modern contraceptive methods of their choice. Key messages/asks In order to ensure universal access to high quality and affordable contraceptive supplies for young people based on their needs, we call upon governments, CSOs, research institutions, the private sector and the international community as a whole to: 1. Empower young people by giving them accurate, youth-friendly and age-appropriate information on SRH methods and how to find trusted health facilities, so they can make their own method choice. 2. Invest in technology solutions and innovative ways of sharing information to ensure young people, especially the very hard to reach, have full knowledge about sexuality, reproduction and contraceptives, and access the method of their choice. 3. Develop country youth strategies around SRH and/or strengthen existing youth SRHR policies to include robust language on access to a wide range of RH supplies for young people. 4. Advocate for the implementation of existing or new youth RH supplies policies supported by necessary funding. 5. Disseminate existing youth RH supplies-related policies to key stakeholders, including youth organizations, to ensure broader knowledge of the existence of these policies, ensure their implementation and use them as best practices for other countries. 6. Address myths and misconceptions around contraceptives and sexual pleasure arising from social norms, religious beliefs and cultural barriers (e.g. pressure to have early pregnancy after marriage, and misconceptions that contraception encourages extramarital sex/infidelity, or that IUDs impact future fertility, etc.). 7. Make available guidelines for all health providers and facilities to use when providing supplies to young people, including in specific situations such as humanitarian/ relief settings. 8. Continue removing legal barriers that limit access (e.g. abortion restrictions, parental/spousal consent, etc.) and developing policies that strengthen access (e.g. youth friendly service provision, Comprehensive Sexuality Education, etc.), but also dare to think innovatively about new approaches that lift the barriers for all young women and men. 9. Acknowledge that young people are best placed to identify barriers and solutions as well as roll out country level work to increase access to supplies among their age group. They should therefore be engaged and participate at all levels including policy, planning and implementation. They can support the collection of data, supply delivery, advocacy, social monitoring, product development and tracking stockouts. 10. Invest in training, mentorship and leadership opportunities for young people and youth organizations that may include, among others, understanding of supplies data for advocacy, and how to conduct dialogues with decision makers. 11. Set standards or disseminate existing standards and organize trainings for manufacturers, pharmacists and service providers in country to help them better understand young people’s needs and provide more effective RH supply services and counseling tailored to youth. 12. Increase research to have better and more disaggregated data on young people’s access to RH supplies, include young people in the data collection process and invest in appropriate mechanisms to share and socialize this data. 11YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE KEY MESSAGES 13. Reach more young people by setting up confidential, affordable youth-friendly and youth-led health settings where they can access supplies, not only through the traditional youth-friendly corners but also via creative ‘new’ spaces that young people may be more likely to attend (schools, private sector facilities, pharmacies, mobile outreach, etc.) 14. Brand the products and tailor the marketing towards young people based on their needs in order to make the products more attractive to youth. 15. Integrate SRH services into the provision of primary healthcare services and universal health coverage (e.g. the integration of vaccine outreach and family planning counselling/supply of family planning methods to those young people that need them) 16. Make menstrual care products available and affordable for all girls and young women, to minimize health problems and absence from school or work. 17. Strengthen inter-sectoral (health, education, labor, etc.) collaboration to promote youth access to RH supplies 18. Build community support for youth access to RH supplies by engaging religious leaders, community leaders, parents, and teachers in dialogue and gathering their input into program planning. 12YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS The Tools This toolbox can help Youth Caucus members to advocate around the key messages in their country, region or at international political levels. By going through the seven steps outlined below, members will have a clearer understanding about how to use the key messages in the most effective way. All the tables presented in this guideline are available online for you to download and use. Gathering data on your region To advocate effectively, you need a good understanding of how young people access contraceptives currently in your country or region, the barriers they face and the needs they struggle with. Scan results from international monitoring systems based on universal indicators, review national policy frameworks about adolescent’s access to RH services and supplies, and find out what international agreements your country signed related to the issue, etc… The International Lesbian, Gay, Bisexual, Trans and Intersex Association Europe (ILGA-Europe) produced a reference guide of international core and supporting documents relating to sexual and reproductive rights and health. The full report can be found here: http://bit.ly/2yR9sMT Here is a brief overview of international agreements on young people’s access to reproductive health supplies: Access to reproductive health supplies › The Program of Action of the International Conference on Population and Development (ICPD): http://bit.ly/1OPfayH › Family Planning 2020 Commitment Makers: http://bit.ly/2x9AXnt › Global Program to Enhance Reproductive Health Commodity Security (GPRHCS) Sexual and reproductive health and rights › Beijing Conference on Women (1995): http://bit.ly/1tY3vC9 › The UNGASS Declaration of Commitments on HIV/AIDS (2001): http://bit.ly/2xUOHSu › Sustainable Development Goals: http://bit.ly/1Kjkn0B Interesting international review and monitoring systems are: › WHO’s Maternal, newborn, child and adolescent health policy indicators: http://bit.ly/2hHM541 › WHO’s Country Profiles: http://bit.ly/1tJgLMW › UNFPA’s Adolescent and Youth Dashboard: http://bit.ly/2yDmFId › PRB’s Youth Family Planning Scorecard: http://bit.ly/2pVXpLF Policy frameworks differ a lot from country to country but it can help to look at the following policy documents in your country: › National Health Pl (and other specific health policies) › National Education Framework (inclusion of sexuality education in the curriculum) › National adolescent’s and youth policy 13YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS The following might be a useful set of guiding questions in order to get relevant data out of policy documents: › Are there legal restrictions to accessing RH supplies based on age or marital status? › Do young people require consent from a parent, spouse or provider in order to access RH services, counseling or supplies? › What is the legal status of abortion? › Does comprehensive sexuality education include information about reproductive health methods? › Is there a form of reimbursement for reproductive health services and supplies in general? Are there any specific measures for young people? › What reproductive health methods are available for young people in your country? Does it cover the full range of methods on the market? › Where can young people find information on reproductive health services and supplies? Selecting focus messages Most key messages are a global assessment of all requirements and may need adaptation to the national or local context to make them effective and relevant. It is therefore vital to identify your focus messages that can be most effective in your sphere of influence and relate as many of them as possible to your organization’s work. Tool 16 helps define priority messages. By answering the questions per key message, you will be able to establish how important the message is in your context and whether or not your organisation is the best stakeholder to take this forward. Once you have answered the questions for all the key messages, you will be able to rank them in order of importance and relevance from 0 (relatively unimportant) to 5 (very important) to arrive at the most relevant messages for your work and pick them as your focus messages. Empower young people by giving them accurate, youth-friendly and age-appropriate information on SRH methods and how to find trusted health facilities, so they can make their own method choice. Invest in technology solutions and innovative ways of sharing information to ensure young people, especially the very hard to reach, have full knowledge about sexuality, reproduction and contraceptives, and access the method of their choice. 1 2 Do you consider this message as an issue that is relevant for the young people in your country/region? Why? What is the current situation in your country/region regarding this issue? Are there still gaps that need to be addressed? Are there other organizations working on this issue? Rank the message based on relevance for your organization to address this. 1 2 3 4 5 0 (not important at all) - 5 (very important) Do you consider this message as an issue that is relevant for the young people in your country/region? Why? What is the current situation in your country/region regarding this issue? Are there still gaps that need to be addressed? Are there other organizations working on this issue? Rank the message based on relevance for your organization to address this. 1 2 3 4 5 0 (not important at all) - 5 (very important) TOOL 1 | SELECTING FOCUS KEY MESSAGES 2YOUTH ADVOCACY KIT 6. Based on the Issue Choice Matrix from Influencing the Post-2015 Development Agenda – Advocacy Toolkit yes, there is a lack of quality Comprehensive Sexual education. young people have few access point for quality and age-appropriate information. Among 15-19 year olg girls. the majority is not using contraception while being sexually active There are no legal limitations to access RH supplies, but the existing policies do not include provision of a full range of methods. High unmet need and contraceptive use is limited to male condom and injectables One of the bigggest obstacles is social stigma on adolescent sexuality, this means young people have no acces points for inofrmation (not from parents or CSE). Big gap between legal situation and social environment Yes, there are a few CSO working on access to RH supplies and youth-appropriate information that are also members of the RHSC. E.g. PHU Uganda, Allied Youth Initiative, Teenage Health Education Centre, etc. 14YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS Identify target policy makers When communicating a complex message or advocating for a sensitive issue, it is crucial to consider for whom this message is intended. Policy makers are responsible for creating new laws and adapting or abolishing existing policies. Therefore, they are crucial stakeholders to inform about the Key Messages document and advocate for appropriate action. When targeting policy makers, it is important to show what can be done to increase young people’s access to reproductive health supplies, to offer them ideas on how to make this change and support them technically. Keep in mind that policy makers are accountable to their constituents and the public opinion and are are always interested in improving their public image and willing to support causes that can count on a wide base of community support. Start by identifying the most important policy makers related to young people’s reproductive health. Analyse their influence, attitude and level of support in relation to your priorities. Tool 2 will help you to do so and map policy makers in your area based on their influence, attitude and affiliation with youth and access to reproductive health supplies. Each policy maker will require a different approach regarding his or her support for your cause. POLICY MAKER MATRIX Are these policy makers working around youth and/ or RH supplies issues? How much influence do these policy makers have on youth and/or RH supplies issues? What is their attitude towards increasing access to RH supplies for young people? Does your organisation has a (in)direct connection to the policy maker and is it easy to reach out to them? Rank the message based on relevance for your organization to address this. TO O L 2 | PO LICY M AKER M ATRIX 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 0 (not important at all) - 5 (very important) 0 (not important at all) - 5 (very important) 0 (not important at all) - 5 (very important) 0 (not important at all) - 5 (very important) Policy Maker: Policy Maker: Policy Maker: Policy Maker: 12 YO U TH ADVO CACY KIT Both,In different national policy documents (like the Family Planning CIP),adolescents are identified as a top priority. The provision of Youth-friendly FP service aslo features prominently across Uganda’s policy documents. Health is identified as a national prority under the development of Human Resources. Under Health, improving Maternal and Reproductive Health are focal points. As well as funding for drugs and commodities.Overal, Health is an important policy area. The Ministery of Health is a member of the RHSC and undersigned our vision regarding RH suppllies. Increasing age-appropriate information, access, and the use of FP amongst young people, is one of five priorities in the Family Planning The Ministry of Health is a member of the RHSC.Several health officials are part of Implementing mechanism listservs. Indirect link through network of CSOs that are also in contact with the RHSC Uganda - Ministry of Health 15YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS Adapt your messages to the audience Once you have identified your messages and your policy makers, it is important to identify the best way to communicate your messages to your audience in order to have the best possible impact. Tool 3 can help to better tailor your messages to your audience. By identifying the main concerns and/or interest of your target policy maker, you will see what part of your message will be easier to get support on. Using arguments that best match the interest of your target policy maker will increase your chances of success. Broadly, for example, apply a human rights framework towards the Ministry of Youth, a public health perspective towards the Ministry of Health and cost-efficiency approach towards the Ministry of Finance. TOOL 3 | ADAPTATION OF THE MESSAGES TO YOUR AUDIENCE AUDIENCE PRIORITIES / MAIN INTEREST RELATED KEY MESSAGES 14YOUTH ADVOCACY KIT Main vision: ‘A healthy and productive population that contributes to socio-economic growth and national development’:- Health as an economic lever for growth- Stress added value of YFS to well-being and capacity of adolescents to work. 1. Empower young people by giving themaccurate, youth-friendly and appropriateinformation on SRH methods and how to find trusted health facilities, so they canmake their own method choice.Uganda - Ministry of Health 16YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS Analyse the policy making process and identify advocacy opportunities There are many ways to influence decision-making. Advocacy activities are conducted to persuade your targets to move towards your policy objectives. This requires analysing the decision-making process and identifying essential windows of opportunity where you are more likely to get attention for increased access to reproductive health supplies for young people. Questions to consider could be: › What is the decision making process when it comes to youth and reproductive health supplies related issues? › Who is involved in which stage of the decision process (Ministry, Parliament, public administration…)? › Is there a formal space for civil society consultations? › What is the expected duration of the process? › Are there any important activities coming up that might affect the political process (e.g. elections)? It is always good to do this research in collaboration with other stakeholders; they might have more information about the process. Reach out to your contact persons in political institutions to gain understanding of the process and ask them to help identify windows of opportunities. Use this information to identify one to three advocacy opportunities coming up that should be the focus of your upcoming advocacy work. Develop an action plan After you have gathered all the relevant information and have some advocacy opportunities in mind, it is time to develop an action plan. It will specify which actions need to be taken towards which specific policy maker and put a clear timetable against it. The first steps of developing an action plan have already been completed, choosing an overall goal and selecting a specific focus. In order to make your goal as concrete and effective as possible it is good to ensure it is SMART (Specific, Measurable, Achievable, Relevant and Time-bound)7. There is wide range of activities to influence the decision- making process. The box below presents an overview of possible activities that can be carried out. BOX 1: EXAMPLE ADVOCACY ACTIVITIES Panel discussions: Invite young people, experts and policy makers to discuss the issues at hand Lobby meetings: Arrange private meetings with different stakeholders to discuss the issue and explain clearly what they can do to help. Having a good contact with the stakeholders involved will increase your knowledge and involvement. Site visits: Organise visits to young communities affected by insufficient access to RH supplies together with the stakeholders, this can put a human face to the numbers and facts. Public outreach: Involve the community directly through consultations, open letters signed by hundreds or a public rally that invites stakeholders to meet all who cares. Media outlets: Opinion editorials, radio broadcasts and social media campaigns are powerful tools to create visibility and demand attention for your advocacy targets. Visual campaign ads: Design a campaign and include merchandise and / or advertisements (posters, promotion clips, stickers, videos etc.) to build recognition of the issues. 7. http://strachanfoundation.org/english/resources/smart-objectives/ 17YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT THE TOOLS The next step is to develop indicators that will measure the progress or extent of the success of the activities. Indicators should be clearly formulated to optimize measurability. There are two types of indicators. Outcome indicators determine the extent to which you have successfully reached your objectives and your advocacy asks have been met. Output indicators should directly reflect the numerical output from the activities conducted or the extent to which they were completed. Box 3 below gives some examples of these two kinds of indicators. For every activity, it should state which partners (other organisations, government representatives…) were involved in order to ensure all relevant stakeholders are included and a clear division of labour can be guaranteed. Establishing a timeline will ensure that the activity spans a realistic and feasible period of time. Check your timeline with the partners involved and make sure it takes into account national / international windows of opportunity (conferences, budget cycles, etc.) Tool 4 is a simple example of how an action plan can look: BOX 2: EXAMPLES OF OUTCOME AND OUTPUT INDICATORS Outcome indicators › Policy-makers pass a bill in parliament › Community health centres offer new services › Comprehensive sexuality education is made available in a certain school › Increased access to reproductive health supplies through innovative projects Output indicators › Number of meetings with › Policy-makers › Number of workshops organised › Number of people that attended seminars TOOL 4 | ACTION PLAN ACTIVITIES INDICATORS PARTNERS INVOLVED TIMELINE 16YOUTH ADVOCACY KIT Hold workshops to engage peers to educate young people about YFS for RH services. Recruit adolescents to become Champions on YFS in their community YFS workshops held (target: 12 camps)Amount of adolescents reached (target: 360)Amount of YC recruited(target: 36) Youth CSOsLocal schools and communitycentersMinistry of Health 1 yearPossible key events:National FP conferenceStart of the school year 18YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Monitoring and evaluation By following the previous steps, you now have a strong action plan to advocate for adolescents’ access to reproductive health supplies. During the implementation of different activities, it is important to monitor the progress on a regular basis, so all parties involved are held accountable for their part in the action plan. Evaluate the project and the actions taken on a regular basis and provide recommendations to strengthen or re-adjust efforts and take note of important takeaways for future projects. This set of questions can help you self-monitor the action plan: › Which of your desired targets are you reaching? Are you falling behind on other targets, and if so, why? › Do the indicators still accurately reflect what you want to track? If not, can you adapt them more to your evolving needs? › What activities are showing the best result? What activities don’t seem to have the expected effect? What is the reason for that? Could they be improved? › Has the collaboration with partners been helpful? Or rather has it provided obstacles? › What messages were most useful in your advocacy work? › What were barriers to success? What facilitated success? The information you collect by answering the questions above should allow you to answer the three key questions in order to move forward: 1. What did not work well and should be stopped? 2. What worked well and should be continued in the future? 3. What new activity could help achieve your goals and objectives? Monitoring and evaluation is an essential part of the advocacy process. It allows you to build on previous activities and learn from the experiences of other stakeholders. Tracking the progress of the action plan makes sure that activities can be re-adjusted at any time to make sure the action plan is up-to-date and any changes in the policy environment are included. Tool 5 allows you to monitor the action plan and the progress of your planned activities on a regular basis. THE TOOLS MONITORING AND EVALUATINGTHE ACTION PLAN Which of your objectives are you reaching? Are you falling behind on certain objectives, and if so, why? Do the indicators still accurately reflect what you want to track? If not, can you adapt them more to your needs? Has the collaboration with partners been helpful? Or rather an obstacle? Is the timeline still realistic? If not, what is the reason for this? What are barriers to success? What facilitated success? TO O L 5 | M O N ITO RIN G AN D EVALUATIN G TH E ACTIO N PLAN Activity: Activity: Activity: Activity: 18 YO U TH ADVO CACY KIT Peer education workshops onYFS for RH services.YFS workshops held: Target 12 / held: 10Amount of YC recruited: Target 36 / recruited:25Amount of adolescents reached: Target 360 / reached:100The groups signing up are smaller (15-20). A lot of youngpeople are hesitant Social sitgma on the sexuality of adolescents. parents are often hesitant to allow their children to participate in off-school events Yes, most targets are still on track. With extra effort we will also reach the desired number of 360 young people Schools were hestitant to organise workshops duringhours and linked to the schools. With support from the MoH they are turning around Yes, we added an extra indicator. YC need to follow an extra course and take a test to get certified. Certified YC Target: 30 The support from the Ministry Health is helping to connect schools and difficult to reach 19YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Tool 6 can be used to evaluate the action plan and its activities and provide recommendations to strengthen or re-adjust efforts and take note of important takeaways for future projects. THE TOOLS ACTIVITIES INDICATORS WHAT WORKED WELL? WHAT DIDN’T WORK WELL? OVERALL CONCLUSION WHAT NEW ACTIVITY COULD HELP ACHIEVE YOUR GOALS AND OBJECTIVES? TO O L 6 | EVALUATIO N O F TH E ACTIO N PLAN 20 YO U TH ADVO CACY KIT Hold workshops to engage peers to educate adolescentsabout YFS for RH services.Recruit participating young people to becomeChampions on YFS in their community YFS workshops heldtarget 12 / held : 20Adolescents reachedtarget: 360 / result: 410 Champions recruitedTarget 36 / result 60 Champions certifiedTarget 30 / result 20(still ongoing) Targetting schools was difficult in the beginning,but number of participantswas higher compared withprivate wrokshops.Attendees were veryactive and high number wanted to become a youthchampions Private organizedevents had low attendees,Important to advocate workshops towards parentsand the full community. Difficult to oversee all the youth champions and theirown activities after the workshops The activity was a succes. A lot of new peer educatorssigned up, but it was proofed necessary to do a follow-uptest and award certifiactes to maintain control over the quality of new initiatives Next steps are: Develop guidelines and a supportsystem for the Champions toorganise workshops in their community. Work with schools to include workshopin school curriculum ones a year. 20YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE Engaging Online: Best-practices and tips & tricks to engage effectively online with young people Modern day technological innovation has brought forth an expansion in the reach of internet and mobile networks, improving the access to information for millions of young people around the world. This provides reproductive health advocates with the possibility to empower and reach adolescents to improve their access to reproductive health services, supplies and information about their needs. This part of the handbook provides an overview of best practices of innovative ways for advocating the importance of focusing on young people and also innovative tools for directly improving access to RH supplies and services. Communicating on sexual and reproductive health is a sensitive subject in many societies. Engaging around these topics online is further complicated by other barriers, regarding language, cultural differences, and the different use of social media by age groups. The second part of this section therefore provides tips and tricks to improve the efficiency and quality of online advocating and communicating about sexual and reproductive health. 21YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE JamboMama! What: Interactive mobile application that connects pregnant women with maternal healthcare services. Innovation: Through the app the most vulnerable communities are reached and linked to the management information system. Who: Smart Access To Health for All (SAHFA) Where: Uganda Link: http://smartaccesstohealthforall.org/jambomama/ Best-practices of innovative tools This section lists existing tools, like apps, virtual reality, comic books, etc. that work on increasing access to reproductive health supplies for young people. Hopefully it can inspire future work in other countries or regions. Apps #DÓNDE What: Open-source platform helping users locate quality youth-friendly RH services and access points for supplies Innovation: Young people informing each other about RH services received by submitting reviews of the RH services that users received at the facilities included in #Dónde Who: CEDES in collaboration with Fundación Huésped Where: Argentina Link: https://donde.huesped.org.ar/#/ Other mobile applications that have a similar way of working are: › Dot: https://gumc.georgetown.edu/news/first-time-real-time-efficacy-study-on-fertility-app-launched › Zero Mothers Die: http://www.zeromothersdie.org/ › Safe Delivery: http://www.maternity.dk/safe-delivery-app/ › Suyojana: http://www.swasti.org/mobile-decision-support-application 22YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Virtual Reality Comic Books Interactive website Streets of Aleppo What: Virtual reality fundraising campaign that takes people to the devastated streets of Aleppo (Syria). Innovation: Offering viewers an experience to see with their own eyes that horrors of barrel bombing are happening in real time, provides a stronger connection with the issues. Who: Amnesty International Where: United Kingdom Link: https://www.amnesty.org.uk/press-releases/first-use-virtual-reality-fundraising-hit-members-public Chasing Dreams What: Comic Book and facilitator guide to raise awareness of the HIV-related challenges migrants, mobile workers, face and the communities with whom they interact. Innovation: Participatory created comic through workshops and interviews to capture real-life stories and issues Who: International Organisation for Migration (IOM) Where: Namibia Link: http://www.comminit.com/srhrafrica/content/chasing-dreams-comic-book-and-facilitators-guide Zanzu.be What: Website about sexual and reproductive health in 13 multiple languages Innovation: Having all the sexual and reproductive health (SRH) information in 13 languages in one place, including an audio tool for blind people. Who: Sensoa / German Federal Centre for Health Education (BZgA) Where: Belgium Link: http://www.zanzu.be ENGAGING ONLINE 23YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT WhatsApp Social arts Online campaign Health for All Coalition (HFAC) Whatsapp Group What: Whatsapp Group to promote government investment in reproductive health and family planning services. Innovation: Using Whatsapp as a simple, cost-effective means of reaching out to policy influencers and decision makers. Who: Health for All Coalition (HFAC) Where: Sierra Leone Link: https://amplifychange.org/news/-/what-does-whatsapp-have-to-do-with-advocacy-for-family-planning- budgets_67/ Youth Champion’s initiative: Art, Poetry, and Justice What: A two weeks program that aims to discuss and organize around different issues, including reproductive health while using creative arts as learning mechanism. Innovation: Linking SRH to the expression of emotions through dance and art. Who: Art, Poetry, and Justice Where: United States Link: https://www.facebook.com/art.poetry.justice/posts/1261056700591907 #AFRIENDOFMINE What: Online campaign that uses the myths on sexuality to start spreading the truth about contraception. Innovation: Using funny and striking myths in a very visual way to catch the attention of young people to talk about correct and less attractive information about contraception. Who: World Contraceptive Day Where: International Link: https://www.your-life.com/en/a-friend-of-mine/ ENGAGING ONLINE 24YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE Tips & tricks to engage effectively online with young people Overcoming online barriers Yet, while these are great tools, many young people face significant barriers to online communication. Social media and the internet provide great opportunities for these programs but it is important not to overlook the many barriers online communication faces. Language Barriers Young people need age-appropriate and accurate information on sexual and reproductive health topics, like Reproductive Health (RH) supplies and contraceptives. It is important to use youth-tailored terminology that takes into account the fact that the needs of young people are very different from adults. Example UNSUITABLE SUITABLE Family planning Future planning: Young people are often not managing their sexual activity in the context of having a family. It is a way to plan their future in terms of their education, their relationships and their finances. Sexual transmitted Dis- eases (STDs) Sexual Transmitted Infections (STIs): The word diseases has many negative associations and has the effect of making people think twice about having sex. This is not the intended effect of preven- tion and raising awareness around STIs. Long-Acting reversible Contraceptives (LARCs) A lot of myths and misconceptions exist around the effects of LARCs. Young people think they will become infertile or suffer side-effects. The positive aspects of the methods should be highlighted: Reliable and less expensive in the long run. 25YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE Example Attitudes to non-exclusive sexual relationships, for example, can differ between two neighbouring communities. The way sexuality is perceived has a major impact on the work of reproductive health supplies advocates. In some communities, having more than one sexual partner is common and culturally acceptable, particularly among young men. In others, sexual relationships are seen as exclusive and having multiple non-exclusive relationships is not accepted. RH advocates and community workers need to be aware of these cultural believes about relationships when setting up preventing campaigns or teaching about contraceptive methods. Example › The use of WhatsApp to deliver SRHR information to young people. People are able to receive information on sensitive topics like sexual abuse and safe and enjoyable sex discreetly via their phone. › In India contraceptive services are absent in many parts of India, and it is men who generally have control over whether to use it. Because of this, the Count Me IN! It’s My Body programme8 is designed to enhance access to SRHR information for young girls (12-16 years) using sports as an entry point. › Citizen News Service (CNS) is an Indian-based specialized news service that focuses on health and science. CNS believes that experiential and lived knowledge of key affected populations should be central to driving responses to specific health and development issues. Cultural Barriers Communicating about sexuality and topics like RH supplies for young people makes for a sensitive conversation in just about any culture. This especially applies to contraception, as it implies being sexually active and in many countries, there is still a widespread denial that adolescents are engaging in sexual activity. Many global messages, for example, ignore cultural differences, leading to miscommunication. RH advocates who are trying to improve young people’s access to RH supplies and services need to adapt their messages to the cultural background of their audience and try to understand how they look at different sexual and reproductive health topics. Agents of change Young people have different role models and place more importance on new media channels than adults do. The print media has become far less relevant than it was, and television news is not regarded with as much credibility as it used to be. Role models have also changed; these now tend to be (YouTube stars, Instagram channels, etc.). To spread messages on SR supplies relevant for today’s youth, it is necessary to reach young people through the channels they use the most, such as YouTube, Facebook, WhatsApp, and others) and physical places where young people hang out most (schools, sport clubs, nightlife, etc.) 8. http://www.creaworld.org/sites/default/files/IMB%20Note.pdf 26YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE Example › The Love Life – No Regrets9 campaign wanted to promote safe sex with a manifest that presented a positive sex image. “To enjoy life, I need my body. I protect it from sexually transmitted infections like HIV: if I’m single, cheat on my partner or if a relationship has just ended, I use condoms and play by the safer sex rules. In a faithful relationship, after getting ourselves tested, we can stop using condoms.” › BeforePlay.org10 used humorous sex-positive memes and billboard as part of a safe sex and sex positive promotion campaign. BeforePlay.org is a organization that provides tools and information necessary to make safe-sex education fun, easy to understand and even easier to talk about. Focus on a positive sex message when communicating with young people Steer away from the many negative stereotype about sexuality communicating sexual health and well-being to young people is not only about preventing sexually- transmitted infections, but also about enjoying positive, healthy, fulfilling, and violence-free expressions of sexuality. 9. http://www.lovelife.ch/en/the-manifesto/ 10. https://beforeplay.org/ 27YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE Tips & Tricks to improve online communication Write short paragraphs and avoid jargon When writing online about reproductive health supplies: 1. Keep your paragraphs short and clear. Large blocks of text are tough to get through online. 2. Use quotes. Use as many quotes as you can -- to bring other voices into the story. Quotes also help break the story up visually and make things more interesting. 3. Don’t use jargon! Reproductive health language includes a lot of technical terms and a very specialized vocabulary. Always explain what things mean and provide a glossary if you can. This also counts for abbreviations like SRHR, EC, etc. Example JARGON COMMONLY USED TERM Evidence-based approach Based on or supported by research Lower wealth quintiles Lowest incomes Commodities Supplies Use visual tools Advocating access to reproductive health supplies often involves complex data to support the policy. Statistics and numbers can be explained more easily if they are presented as infographics, interactive presentations or videos. Use empowering images Steer away from negative stereotypes as they often communicate pointlessness and inevitability. Examples of negative stereotypes are people suffering or in a state of desperation. On the other hand, overly positive images displaying wealth or technology will create the illusion that support or extra effort is not needed. Good images show real situations and the circumstances people have to deal with when accessing reproductive health supplies. They show what is being done to ensure people have access to quality reproductive health supplies and enabling them to make decisions on their own. Example › This infographic from Women Deliver advocates for investing in adolescents by visualizing the issues they face and how to change their lives: http://bit. ly/2xfT0IY › Population Action International (PAI) uses infographics to visualize a wide array of topics related to reproductive health. The following infographic is used to advocate the urgency of reproductive health in humanitarian emergencies: http://bit.ly/2xgkRDT Source: PHAU campaigning access to RH supplies - Copyright © 2017 Photoshare & David Alexander, Johns Hopkins Center for Communication Programs. 28YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Be proactive and to the point If your goal is to reach as many people as possible make it easy for your target audience to find you online through common interest sites. › Tap into the network of partner organization with a similar audience, If it is for launching a new project, organizing an event or simple publishing an article on your website. › Always use clear and to the point titles when posting on social media (a news item or update on your activities). This is so that people scanning through their newsfeed know what it is about without having to read it first. › People have multiple interests and a busy agenda. Make sure you repetitively announce upcoming events or projects in order to remind your audience of your activities. Using Hashtags Be super specific when choosing hashtags to be as relevant as possible to your chosen audience. When reaching out to parents of adolescents on the importance of contraceptives, do not only use #Parents because this, of course, applies to all parents everywhere. To target parents with an interest in contraceptive methods try for example #MyTeenageDaughter, #KidsHealth, #RaisingGirls, # etc. If you are creating a new hashtag, you should try to keep it brief. Hashtags are supposed to make things easier to find and engage with, people will not search for long and complicated hashtags. Nobody will search the following examples on his or her own: #preventingteenagepregnancyforgirls, #StandUpForVictimsOfSexualHarrasment, #EmpowerYoungPeoplesContraceptiveChoice, etc. It is better to combine different hashtags for your message (e.g. #EmpowerAdolescents #ContraceptiveChoice) or use simpler hashtags (e.g. #EndTeenagePregnancy). Analyse and evaluate your reach Advocating for access to reproductive health supplies is in part about creating awareness and reaching as many people as possible. It’s important to engage with your audience and understand how they search for and process information. This means not only informing them about upcoming events or campaigns, but also asking their opinion and feedback on the quality and efficiency of your projects and online content in order to evaluate and strengthen it. There are many free monitoring and analytical tools available11, like Google Analytics, Buffer or tools for a specific social media channel (e.g. Followerwonk for twitter). These tools allow you to see how long visitors spend on reading an article, which pages they open or which platforms they use to share content. To understand how to expand your reach and effectively communicate your messages to your audience, working with them and learning from their internet use is a wise approach. ENGAGING ONLINE Example › WhatsApp is an ideal platform to share and discuss articles about sensitive issues (e.g. Sexually Transmitted Infections), because it is more privately compared to posting it on Facebook. › More websites are now loaded on smartphones and tablets than on desktop computers. This means your website needs to responsive to all mobile devices. › In the United States, only 22 percent of the people aged 30-49 use Twitter, but 79 percent of them use Facebook. Research how to reach a certain audience ( e.g. parents) before you start promoting your campaign. 11. https://blog.bufferapp.com/social-media-analytics-tools 29YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT Use multiple channels Reaching your audience may require using multiple media channels. This is because every media platform (online or printed) has its own benefits and characteristics. Platforms differ in the content people use it for (hard news, watching videos, reading long articles, browsing through photos, etc.) and the age demographics of users. When targeting adolescents, remember that 37 percent of Instagram users are aged 16-24, compared to just 25 percent of the Facebook users12. Another study13 on how Americans gather news showed that Facebook reaches 67 percent of all US adults (18-65+) and 44 percent of its users get news on the site. On the other hand, only 9 percent of Twitter-users and just 4 percent of Instagram users, use those platforms to gather news. These different statistics show that it is important to use multiple media platforms to spread your messages, as well as adapt these messages on who is more likely to access them on those platforms. ENGAGING ONLINE 12. https://www.statista.com/statistics/274829/age-distribution-of-active-social-media-users-worldwide-by-platform/ 13. http://www.journalism.org/2016/05/26/news-use-across-social-media-platforms-2016/ 14. https://medium.com/its-about-supplies 15. https://storify.com/ 16. https://www.rhsupplies.org/activities-resources/webinars/video/safety-of-contraceptives-for-young-people-65/ 17. https://soundcloud.com/ Example Storytelling: › Medium14 is a new publishing platform that allows user to present long reads, interviews, photographic documentaries, etc. People that visit this platform are more inclined to spend time reading long articles than when you share it only on Twitter or Facebook. This as article about Women and Family Planning Markets on the ‘It’s about Supplies page of the RHSC. › Storify15 is a social network service that can be used to create stories or timelines combining text and messages from other social media applications like twitter, Facebook or Instagram. It is commonly used for covering ongoing events, like elections or conferences. Panel Discussions › A Webinar is an online seminar that allows to organize interactive presentations, workshops etc. It is an easy tool to bring people together around an issue at any given moment. This is a webinar hosted by the RHSC on the Safety of Contraceptives for young people16. › Podcasts or audio presentation are also a useful way to share information and organize a discussion. Youtube or Soundcloud17 are two commonly used channels for creating podcasts. 30YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ENGAGING ONLINE Explore offline tools and presence People in rural and remote areas don’t always have access to (or don’t have the required skills to use) the internet or mobile apps. To ensure access to reproductive health supplies for all it is important to reach out to people who cannot be reached by most modern communication tools. This requires disseminating information through words and images. Paper is still a great analogue tool to spread messages through flyers, posters, books or even comic books. Using images is also a way to deal with poor literacy. Example › The Circus Girl18 is a Comic book about a teenage girl that starts experiencing breast development and menstruation and looks for advice from family members and health workers in her community. The Circus Girl wants to promote awareness and address adolescent issues and problems. This comic book is part of the “Know Yourself” Adolescent Reproductive Health (ARH) Communication Program, developed by the Bangladesh Center for Communication Programs (BCCP), ARH Working Group and Johns Hopkins University Center for Communication Programs.A wide range of issues are covered in Kiss Me Deadly , a comic book published by the Healthy Aboriginal Network. From respect and communication in relationships, to pregnancy and sexually transmitted infections. › Not Your Mother’s Meatloaf19, is a series of sex education comic books. The writers have held an open call for young people to create comics that address a variety of topics involved with sex education. The comics address topics like body image, safer sex, consent, and relationships, from positions that have historically been left out of sex education. 18. https://thehealthyaboriginal.net/wp-content/uploads/2014/04/Kiss-Me-Deadly.pdf 19. https://www.goodreads.com/book/show/16129281-not-your-mother-s-meatloaf 31YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT STAY IN TOUCH! Stay in touch! Inform us about your work! As the RHSC we are interested to hear about the advocacy work you have done around the key messages and would be happy to include any suggestions or recommendations in our future work. Please inform us: Emilie Peeters Advocacy Officer, RHSC epeeters@rhsupplies.org David Eeckhout Intern, RHSC deeckhout@rhsupplies.org 32YOUNG PEOPLE AND CONTRACEPTIVE ACCESS: AN ADVOCACY AND COMMUNICATIONS TOOLKIT ANNEX Annex Bibliography Bellizzi, S. S. (2015, February 3). Underuse of modern methods of contraception: underlying causes and consequent undesired pregnancies in 35 low-and middle-income countries. Human Reproduction, pp. 973–986. Blanc, A. K. (2009). Patterns and trends in adolescents’ contraceptive use and discontinuation in developing countries and comparisons with adult women. International perspectives on sexual and reproductive health, 63-71. Calhoun, L. M. (2013, December 23). Provider imposed restrictions to clients’ access to family planning in urban Uttar Pradesh, India: a mixed methods study. BMC health services research, p. 523. Castle S., A. I. (2015). Contraceptive Discontinuation: reasons, challenges and solutions. New York: Population Council / FP2020. DFID Nigeria Human Development Team. (2011). Scaling up access to contraceptive commodities in Nigeria. London: British Department for International Development. Gilda Sedgh, L. S. (2016). Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method. New York: Guttmacher Institute. Gueye, A. S. (2015). Belief in Family Planning Myths at the Individual And Community Levels and Modern Contraceptive Use in Urban Africa. International perspectives on sexual and reproductive health, 191-199. Ochako, R. M. (2015). Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study. BMC public health. Polis, C. B. (2016). Contraceptive failure rates in the developing world: An analysis of demographic and health survey data in 43 countries. New York: Guttmacher Institute. Ross, J. K. (2015). Trends in the Contraceptive Method Mix in Low- and Middle-Income Countries: Analysis Using a New “Average Deviation” Measure. Global Health: Science and Practice, 34-55. Schwandt, H. M. (2017). Contraceptive service provider imposed restrictions to contraceptive access in urban Nigeria. BMC health services research. Simon, C. (2016, February 29). Shaking Up the Conversation about LARCs for Youth. Retrieved September 11, 2017, from Pathfinder International: http://www.pathfinder.org/shaking-up-the-conversation-about-larcs-for-youth/ Speizer, I. S. (2000, March 1). Do Service Providers in Tanzania Unnecessarily Restrict Clients’ Access to Contraceptive Methods? International Family Planning Perspectives, pp. 13-42. Stanback, J. &.-B. (2001). Why do family planning providers restrict access to services? An examination in Ghana. International Family Planning Perspectives, 37-41. Tumlinson, K. O. (2015, August 1). Provider barriers to family planning access in urban Kenya. Contraception, pp. 143-151. Yinger, N. (2016). Meeting the need, fulfilling the promise: Youth and Long-Acting Reversible Contraceptives. Washington D.C.: Population Reference Bureau. The Reproductive Health Supplies Coalition The Coalition is a global partnership of public, private, and non-governmental organizations dedicated to ensuring that everyone in low- and middle-income countries can access and use affordable, high-quality supplies for their better reproductive health. It brings together agencies and groups with critical roles in providing contraceptives and other reproductive health supplies. These include multilateral and bilateral organizations, private foundations, governments, civil society, and private sector representatives. Rue Marie-Thérèse 21 1000 Brussels Belgium Tel: +32 2 210 0222 Fax: +32 2 219 3363 E-mail: secretariat@rhsupplies.org

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