Introduction
Maternal and neonatal mortality Rate is still one of
the major health issues in developing countries like Nepal. In Nepal
(Nepal Demographic and Health Survey, 2001) the median age at first
birth is at around 20 years and the indications are that this has
not changed in the recent past. Among the sample of married women
who are currently 19 years, four out of ten have begun childbearing,
that is, they are either currently pregnant or mothers. Moreover,
this report also shows that childhood mortality is substantially
higher among children born to mothers who are under 20 years of
age. In Nepal, once married, couples especially women often face
extreme pressure to demonstrate their fertility immediately after
marriage. These early pregnancies posses increased health risks
to both the mother and child, and as a result, threaten the health
of future families. In addition, early pregnancy also affects the
education and career development of couples especially women.
The National Adolescent Health and Development Strategy for Nepal
was first developed in 2000 and is intended to guide the Ministry
Of Health (MOH) and all partner agencies in improving the access,
coverage and quality of health services for adolescents.
CARE Nepal is implementing Reproductive Health Project for Married
Adolescent in Dhanusha and Parsa with the aim of improving the
reproductive health need of newly married adolescent couples in
Dhanusha and Mahottari districts of Nepal. The overall attempt
of this project is to create Youth -Friendly Services (YFS) at
health facilities and make the youth/adolescents aware of their
basic RH issues in relation to time and number of pregnancies
vs. their age and develop safe sexual behaviors.
Objectives
The overall objective of the project is to improve
the reproductive health need of newly married adolescent couples
in Dhanusha and Mahottari districts of Nepal. They will be achieved
by:
§ Increasing the use of family planning, maternal health,
and HIV/STI services among married adolescent couples.
§ Increasing the knowledge of providers about the reproductive
health needs of adolescent married couples, including information
related to pregnancy, delivery, and post natal, family planning
and HIV/STIs, resulting in improved access to quality services
for adolescent married couples.
§ Increasing community and family support for reproductive
health decision-making among adolescent married couples, especially
related to pregnancy, delivery and post natal, and family planning
Target Group and Coverage
The project has targeted adolescent married couples
living together (focus on women below 19 years). It also targets
health workers of Health Post (HP) and Primary Health Center (PHC)
in the project districts. The project has covered three VDCs in
each Ilaka (Dhanusha: 14 Ilakas and Parsa: nine Ilaka), hence
covering a total of 69 VDCs.
It is planned to identify nine adolescent couples from each VDC
of the project area. A total of 378 couples from 42 VDCs (three
VDCs per Ilaka) of Dhanusha and 243 couples from 27 VDCs (three
VDCs per Ilaka) of Parsa have been selected to work with them
through out the project cycle.
Implementation Strategies
The project has adopted the following two major strategies
to achieve the overall objective of the project:
Mobilizing adolescents to address their SRH needs: The married
adolescent couples play a pivotal and leading role in all stages
of program design and delivery. To improve program relevance,
effectiveness and a sense of ownership among married adolescent
couples, they are involved in a broad array of activities, ranging
from project design, implementation and evaluation. A total of
9 couples are selected from each VDC (one from each ward) and
they will be trained as Peer Educators (PEs). The training will
include several information, on the available family planning
services and choices, maternal health service provisions, (Ante-Natal
care (ANC), safe delivery, and Post natal Care (PNC) in their
respective communities): The PEs will work as a channel of communication
with other adolescents and influence on their beliefs, attitudes,
and behavior in a culturally appropriate manner; and set positive
examples for their peers to follow. They will also serve as a
source for information on Youth Reproductive Health (YRH) and
provide insights into adolescents' decision-making and information
sharing.
Promoting Youth Friendly Service (YFS): One of the major thrusts
of the project is to promote Youth Friendly Service (YFS) at the
health facilities. This is essential to increase access to Sexual
and Reproductive Health (SRH) services and its utilization among
married adolescents. The health workers in the project area are
trained on the concept of YFS using EngenderHealth curriculum.
Individual action plan for each health facility was developed.
The implementation of the action plan will be monitored jointly
by DPHO and the project to improve access, coverage and quality
of SRH services in the health facilities.
Accomplishment
Major activities accomplished during this reporting
period are as follows:
Office Setup and staff hiring
During the month of June and July office was setup in both the
districts and rapport building was done with District Public Health
Office (DPHO) and health facilities. Informal sharing of project
objectives, strategies and activities during field visit helped
develop good rapport. During May to June'05, staff hiring was
completed. One Project Officer (PO) and three Sexual and Reproductive
Health Facilitators (SRHFs) for each district were hired during
the period. The project staff were oriented about organization
policies and the project immediately after they came into board.
Two additional SRHF
Start Up Workshop
It was envisaged to orient health facility staff and receive their
commitment for the smooth implementation of project. An event
of start up workshop was facilitated in both the districts (see
annex 1 for schedule). The workshop was conducted in Parsa on
13th July'05 and on 23rd August'05 in Dhanusa. The participants
of the workshop were District Public Health Officers (DPHOs),
district supervisors, illaka Incharges and other NGOs members.
The objectives of the workshop were to share objectives, strategies
and activities of the project and to seek feedback and inputs
from DPHO staff in the project.
The workshop was successful to raise interest and obtain commitment
from the DPHO staff. They promised to give their full support
in the implementation of the project. Some of the staff said that
the project would be very much useful for our adolescents to shape
their behaviors so we need to give an environment for our adolescents
through this project.
Training of Trainers (TOT) to project
staff
Though it was not planned in the original proposal, an event
of five-day TOT (see annex 2) was facilitated for project staff.
The training was organized in Parsa district from 15 to19 Aug'05.
A total of 17 participants including focal persons from DPHO of
both the districts received training. The Objectives of the TOT
were to impart knowledge on sexual and reproductive health, enhance
facilitation skills, and to develop common understanding on detailed
implementation plan (DIP).
The training was succinct to enhance the facilitation skills
of the participants and to develop DIP of the project. The project
staff also prepared quarterly plan during training. The training
is a major milestone in the course of project implementation.
The project got momentum and the activities started implementing
rapidly after this training.
Youth Friendly Service (YFS)
One of the major thrusts of the project was to promote Youth
Friendly Service (YFS) at the government health facilities. For
this purpose, it was planned to train health facility staff on
the concept of YFS (see annex 3). The training was facilitated
in two phases. In the first stage, district supervisors and illaka
incharges were trained and in the second phase other health facility
staff such as Auxiliary Health Worker (AHW), Auxiliary Nurse Midwife
(ANM), Maternal and Child Health Worker (MCHW), Village Health
Worker (VHW) and Lab Assistant (LA) were trained. The district
supervisors and illak incharges trained in the first phase were
mobilized as resource person to facilitate training in the second
phase. Altogether, 265 participants were trained on YFS. This
approach of working in two phases has tremendous impact in achieving
desired results within stipulated time. The details of the training
are given below.
- Training to district supervisors
and illak incharges
An event of two-day YFS training was facilitated in both
the districts for district supervisors and illaka incharges.
The district supervisors includes RH focal person, Public Health
Nurse, Immunization Supervisor, Statistical Assistant while
illaka incharge included Health Post Incharges and PHC Incharge.
The training was conducted between 22 to 23 September 28 to
29 September 2005 in Dhanusha and Parsa respectively. A total
of 38 health workers were trained during this phase. The main
objective of the training was to orient and prepare district
supervisors and illaka incharges as facilitators for YFS training.
The trainees were mobilized as trainer in the second phase of
the training.
- Training to other health facility
staff
A total of 11 events of two-day YFS training were organized
for health facility staff. The participants of the training
were AHWs, ANMs, Lab Assistants, VHWs and MCHWs. The training
was conducted simultaneously in both the districts between September
25 and October 5, 2005. The objectives of the training were
to impart knowledge on YFS and to transfer skills so that health
workers can deliver service in a friendly manner to youth and
adolescents. Altogether 144 health workers in Dhanusa and 83
health workers in Parsa were trained on YFS.
At the end of the training all the participants expressed their
willingness to promote youth friendly services at their health
facilities. This can be substantiated by the action plan they
developed during the training during course. All the health
workers developed their action plan to implement YFS.
Peer Education
To improve program relevance, effectiveness and a sense
of ownership among married adolescent couples, the project adopted
peer education approach. The project has planned to select and
train 18 Peer Educators (PEs) from each VDC of the project area.
The following activities have been completed during this reporting
period.
- Selection of Peer Educators
A selection criterion (see box) was developed to select
the PEs and it was shared with DPHOs. After receiving feedback
and inputs from DPHO, the selection criteria were finalized.
The project has started selecting PEs in close coordination
with DPHO and its system. The project had formally requested
DHO (see annex 4 for request letter) to mobilize its system
at VDC level to identify and select appropriate PEs. The Peer
educators are selected in almost all of the VDCs.
In some of the VDCs of Parsa, the selection became quite difficult
because of the rumor that PE will get salary on monthly basis.
This rumor was created because a few organizations are giving
incentive to PEs on monthly basis in similar kind of program.
To overcome the rumor, a meeting was organized with health post
Incharges. The criteria for PEs were again shared and asked
them to lay emphasis on the voluntarism. After the meeting,
the health post incharges went to their working area and communicated
criteria clearly. This has helped to resolve the problem and
all the PES are selected. It is planned to facilitate PE training
starting from October 2005.
- Selection criteria
§ Willingness to work as volunteer
§ Married couple
§ Literate
§ Resident of the same community
§ Open to discuss about SRH matters
§ Less chance of migration
§ Higher priority to marginalized
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