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National Adolescent Sexual and Reproductive Health Programme: Mid-Term Evaluation Report

机译：国家青少年性健康和生殖健康方案：中期评估报告

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摘要

EXECUTIVE SUMMARY Background and rationale Th e Ministry of Health and Population (MoHP) Nepal has endorsed the Nepal Health Sector Programme (NHSP) II (2010–2015), which aims to introduce 1,000 adolescent-friendly services (AFSs) in Nepal by 2015. Towards this, the Government of Nepal is implementing the National Adolescent Sexual and Reproductive Health (ASRH) Programme, which, by November 2012 had covered 516 health facilities in 36 districts. To assess the implementation of the National ASRH Programme, a mid-term evaluation was conducted by the Health Research and Social Development Forum (HERD) in collaboration with GIZ/GFA in selected health facilities in Doti and Banke. Th e mid-term evaluation is part of an operational research to determine the eff ectiveness of the National ASRH Programme and explored the understanding, perceptions and experiences of service providers and adolescents related to the implementation of the National ASRH Programme. Th e main aims of the mid-term evaluation were to: • understand the implementation processes and the wider context as it aff ects the National ASRH Programme in order to provide detailed explanations for the results of the fi nal evaluation; and • identify improvements that can be made to the intervention to increase access by adolescents to SRH services in the remaining period of the programme and ways of improving the likelihood of scaling up the intervention across Nepal. Data was collected for the evaluation in March 2013 in semi-structured interviews and focus groups discussions, mainly with health workers and adolescents, supplemented by peer ethnography interviews and observation by the researchers. As the study was conducted in selected health facilities in only two districts, the fi ndings may not be generalised to other GIZ-supported districts or to the many other intervention districts of the ASRH Programme that are supported by the Family Health Division or other donors. Th is report presents the fi ndings of this research. Implementation of the ASRH Programme Th e evaluation looked at the understanding of health workers about the National ASRH Programme and the extent of conforming with the programme guidelines. Th e National ARSH Health Programme was introduced in 2011 in 14 health facilities in Doti and 13 health facilities in Banke districts. Under the programme, health workers from selected facilities were provided with a two-day orientation about the programme; a display board with the AFS logo; information, education and communication (IEC) materials; and a small fl exible amount of fi nancial support for benches, curtains, and shelves to make the facility more adolescent friendly. Health workers in both of the study districts had attended orientations and understood that the programme is for young people (aged 10–19) undergoing changes associated with adolescence. Th ey said that the programme aims to create an environment that is conducive for adolescents to visit health facilities and receive services including by providing adolescent-friendly services and maintaining privacy. Th ey also understood that the programme is about providing counselling and services to adolescents related to SRH. Although most of the health workers understood that the programme is designed to address the specifi c needs of adolescents, some said that the programme is only about delivering family planning services and safe motherhood services. Although the School Health Programme and the training of peer educators do not form part of the ASRH Programme, health workers mentioned these activities as part of it. Th ey said that these activities have created awareness about ASRH services, which suggests that there should be more coordination between the ASRH Programme and programmes at the school level to create demand for ASRH services among adolescents. Key fi nding 1: All health workers are aware of the National ASRH Programme and its components, except for a few who said that the programme is only about delivering family planning and maternal health services. While the School Health Programme and the training of peer educators are not part of the National ASRH Programme, health workers stressed that these are effective ways to share about the ASRH services available at health facilities. Health workers were asked what activities have been undertaken to implement the ASRH Programme in their health facilities. In all facilities, health workers reported attending orientations, distributing IEC materials and making physical changes to the facilities, such as erecting curtains for privacy. Facilities had also organised orientations for the members of the health facility operation and management committee (HFOMC), female community health volunteers (FCHVs), students, teachers and members of the village development committee. Researchers observed that all of the health facilities had AFS boards displayed in visible places, except for Doti Hospital. Most HFOMCs did not have any adolescent members although some health workers remembered that adolescents had been members on previous committees. Some health workers mentioned schools, the community and peer educators as important in reaching out to adolescents and imparting SRH messages. Key fi nding 2: Health facilities have oriented selected FCHVs, teachers and other people in the village development committee about the National ASRH programme and health workers perceive community awareness to be a key factor in facilitating adolescents’ access to SRH services. Th e study also looked at how health workers are recording and reporting data on the ASRH Programme and what diffi culties they face in doing so. Health workers stated that they complete the monthly reporting form for the ASRH Programme by referring to diff erent registers and send the data along with the HMIS 32 form. Some health workers said that it is diffi cult for them to keep records because they have to look through several registers and suggested a separate recording format for the ASRH Programme. Irregular reporting appeared to be an issue, as was lack of follow-up or refresher training. In relation to monitoring, health workers reported that GIZ/GFA staff visited the facilities along with the focal person from the District (Public) Health Offi ce. Th e issue of limited resources was raised in the interviews – there is no budget to visit health facilities under the programme. An annual review at the district level was suggested by health workers to enable them to address the diffi culties and challenges in implementing the ASRH Programme. Key fi nding 3: The recording and reporting of the ASRH Programme has not been regular and consistent. Health workers mentioned not having a separate recording register for the programme and suggested that the programme be included in the HMIS 32 (monthly reporting format). Interaction between health workers and adolescent users Th e study examined adolescents’ access to health services and the behaviour of health workers in delivering AFSs. In relation to access to health services, health workers said that adolescents visit health facilities mostly for contraceptives, as well as for other SRH problems. Th ey also mentioned that a few adolescents presented with concerns about physical changes and their appearance. Health workers agreed that unmarried adolescents visit health facilities more than married adolescents and adolescent boys more than girls. However, the demand side of the programme is weak, with only a few adolescents reporting that they had visited a health facility for SRH services. Among the focus group discussion participants who had visited a health facility, most said that they visited the facility to take condoms; a few had gone with friends who had sought services for erection problems and rashes around the sexual organs. Other participants said they buy condoms from the nearby medical store instead of visiting the health facility. Most adolescent girls in Doti had not visited a health facility, but in Banke adolescent girls had been to a facility, either for themselves or accompanying their friends or sisters-in-law. Adolescent girls visited health facilities for menstrual problems, the oral contraceptive pill and condoms; some had friends who had been to a health facility for an abortion. Married adolescents reported visiting health facilities for antenatal checkups and vaccinations. Health workers said that sometimes adolescent girls come to ask about pimples or for a remedy for pain during sexual intercourse. In relation to the behaviour of health workers towards adolescents, all health workers interviewed emphasised that there have been signifi cant | X | | XI | changes in their behaviour since the introduction of the ASRH Programme. Th ey said that they used to think that giving young people access to contraceptives would ‘spoil’ or corrupt them and that adolescents should not be talking about SRH or using contraceptives. Now, some even stated that adolescents have the right to know about and use modern family planning methods. All health workers stressed that they do not ask the marital status of adolescents seeking family planning services. Th e study found an increased realisation of the importance of SRH among health workers and of the need to deal with SRH issues in privacy. Th ere is an evident awareness among health workers of how they need to respond to adolescents’ SRH needs. Some of the health workers mentioned that high patient fl ows mean that they cannot give as much time to adolescents as they should. Some health workers pointed to a knowledge gap regarding specifi c aspects of ASRH (e.g. emergency contraception, sexually transmitted infections) and suggested that a training would be helpful on technical aspects of the programme as well as refresher training on other aspects. Th ese comments and the concerns of the focal person at the central level indicate that health workers require better skills to deal with adolescents and further training could be of use to them. Adolescents were asked how health workers responded when they visited the health facility for SRH services. Adolescent boys had mixed experiences, but most gave positive feedback and said that the health workers counselled them well and answered their queries. Th ey also shared that they could take condoms easily from health facilities. Many participants shared that the health workers taught them how to use condoms properly and advised them not to have unprotected sex with multiple partners. Adolescents said that the health workers assured them that they would maintain confi dentiality and privacy. Th e fi ndings of peer ethnography also suggest that confi dentiality is maintained. While most adolescents were pleased with the health workers’ behaviour and said that they would happily go back to the health facility again, some did not have good experiences. Some adolescents shared that the health workers asked whether or not they were married when they went to take condoms. Some of the adolescent boys mentioned that the health workers asked the question in a teasing way or made ‘fun’ of them. Similarly, adolescent girls, with few exceptions, said that they found the behaviour of health workers good and that the health workers talk to them in a friendly manner. Th ese girls also shared that there are separate toilets for males and females. Th ey mentioned that the ‘sisters’ maintain privacy by taking them into a separate room. However, some adolescent girls in Doti were discouraged by health workers’ behaviour. In some cases, health workers were judgmental. Such behaviour from health workers creates a sense of mistrust among adolescents and discourages them from visiting health facilities and discussing problems with health workers. Key fi nding 4: All health workers stated that there have been signifi cant changes in their behaviour as a result of the programme. They shared their previous reluctance to provide contraceptives to adolescents as they thought it would ‘spoil’ them and their previous belief that adolescents should not talk about SRH or use contraceptives. Now, when asked about changes in their behaviour towards adolescents seeking SRH services, almost all health workers expressed adolescentfriendly attitudes. However, one health worker mentioned a gap in the training of health workers, which was also stressed by the focal person at the central level, namely, that, in addition to managerial aspects, such training should also cover more technical knowledge and skills on SRH topics and on the counselling of adolescents in SRH. Key fi nding 5: Health workers were aware of the importance of maintaining privacy and ensuring confi dentiality while providing services to adolescents. They mentioned using curtains or meeting adolescents in ANC clinics, but that high patient fl ow sometimes does not allow them to give much separate time to adolescents. Key fi nding 6: Few adolescents stated that they had visited health facilities for SRH services. Most of those who had visited related positive experiences, while a few had bad experiences regarding the attitude of health workers. According to health workers, unmarried adolescents visit health facilities to access services related to the ASRH Programme more than married adolescents. Furthermore, adolescent boys visited health facilities more than adolescent girls. At the same time, adolescent girls tended to have detailed knowledge about the specifi c health services offered, e.g., for STIs, menstrual problems, acne, pain during sexual intercourse and even abortions. Most adolescents who visited health facilities shared that they were happy with the health workers’ behaviour and that health workers treated them in a friendly and helpful way, did not ask for their marital status and maintained confi dentiality while providing information and services. Adolescents who said that they had never visited a health facility for SRH services were asked their reasons for not visiting. They said that they feared that their issues would be talked about and that they would feel embarrassed. These adolescents were often not aware that health facilities offer confi dential services in private. Boys in particular said that they feel uncomfortable because the health workers are senior to them. Adolescents also shared that in some cases the health workers are relatives, which adds to their discomfort as they feel shy and fear that the health worker might tell their parents. They also said that they fear running into neighbours or people they know at the health facility. Some adolescents said that they could not fi nd the time to visit a health facility because of the long distance to school and the need to do household chores. Instead they shared their problems with friends or their mother and, hence, did not feel the need to visit a health facility. Key fi nding 7: Those adolescents who had not used SRH services were concerned about confi dentiality, which seems to be one of the main reasons for adolescents not visiting health facilities for SRH services, in addition to feeling embarrassed to talk to health workers who are older than them or acquaintances. A set of eight adolescent-friendly IEC booklets on issues related to adolescents’ SRH and rights have been produced and distributed to all public health facilities that provide AFSs and to schools in the catchment area of these facilities as part of the National ASRH Programme. Both the health workers and adolescents who have read the booklets found these materials to be very helpful. Health workers have said that adolescents visit health facilities to read these booklets. Th e health workers maintain that the materials are adequate in quantity for adolescents to come and read, but not for wider distribution, except for in Baijapur where the health workers said that they have been distributing the booklets. Health workers also said that they had distributed the booklets to school libraries and community libraries. In addition to the booklets, health facilities that provide AFSs are provided with ASRH posters, an ASRH fl ipchart and comic book. Key fi nding 8: Most boys interviewed were aware of the IEC materials available in the health facilities, but only a few boys and girls said that they had
机译：执行摘要背景和理由尼泊尔卫生和人口部（MoHP）批准了尼泊尔卫生部门计划II（NHSP）（2010-2015），该计划的目标是到2015年在尼泊尔引入1,000个青少年友好服务（AFS）。为此，尼泊尔政府正在执行国家青少年性健康和生殖健康方案，该方案到2012年11月已覆盖36个地区的516个卫生设施。为了评估国家ASRH计划的实施情况，健康研究与社会发展论坛（HERD）与GIZ / GFA合作在Doti和Banke的选定医疗机构中进行了中期评估。中期评估是确定国家ASRH计划有效性的运营研究的一部分，并探索了服务提供商和青少年与国家ASRH计划的实施相关的理解，看法和经验。中期评估的主要目的是：•了解实施过程和影响国家ASRH计划的更广泛的背景，以便为最终评估的结果提供详细的解释； •确定该干预措施可以做出的改进，以在计划的剩余时间内增加青少年获得性健康和生殖健康服务的机会，以及提高在尼泊尔全国范围扩大干预措施的可能性的方法。 2013年3月，通过半结构化访谈和焦点小组讨论（主要是与卫生工作者和青少年进行的讨论）收集了用于评估的数据，并辅之以同伴民族志访谈和研究人员的观察。由于该研究仅在两个地区的选定医疗机构中进行，因此调查结果可能无法推广到GIZ支持的其他地区，也不能推广到由家庭健康部门或其他捐助者支持的ASRH计划的许多其他干预地区。该报告介绍了这项研究的发现。 ASRH计划的实施该评估着眼于卫生工作者对国家ASRH计划的了解以及符合计划准则的程度。国家ARSH健康计划于2011年在Doti的14个医疗机构和Banke区的13个医疗机构中引入。在该方案下，向选定设施的卫生工作者提供了为期两天的方案介绍；带有AFS徽标的展示板；信息，教育和通讯（IEC）材料；并为长凳，窗帘和架子提供少量的灵活财务支持，以使该设施对青少年更友好。两个研究区的卫生工作者都参加了介绍会，并了解该计划是针对正在经历与青春期相关的变化的年轻人（10至19岁）。泰伊说，该计划旨在创造一个有利于青少年参观医疗机构并获得服务的环境，其中包括提供青少年友好型服务和维护隐私。他们还了解，该计划旨在为与性健康和生殖健康相关的青少年提供咨询和服务。尽管大多数卫生工作者都知道该计划旨在满足青少年的特定需求，但一些人表示，该计划仅用于提供计划生育服务和安全的孕产服务。尽管学校健康计划和对同伴教育者的培训不属于ASRH计划的一部分，但卫生工作者将这些活动作为其一部分。他们说，这些活动已经引起人们对ASRH服务的认识，这表明ASRH计划和学校一级的计划之间应该进行更多的协调，以引起青少年对ASRH服务的需求。关键发现1：所有卫生工作者都知道《国家ASRH计划》及其组成部分，只有少数人说该计划只是为了提供计划生育和孕产妇保健服务。尽管学校健康计划和对同伴教育者的培训不是国家ASRH计划的一部分，但卫生工作者强调说，这些是分享卫生机构提供的ASRH服务的有效方法。卫生工作者被问到在其卫生机构中开展了哪些活动来实施ASRH计划。在所有设施中，卫生工作者均报告参加了情况介绍会，分发了IEC材料并对该设施进行了物理更改，例如为隐私设置了窗帘。机构还为卫生机构运营和管理委员会（HFOMC）的成员，女性社区卫生志愿者（FCHV），学生，教师和乡村发展委员会的成员组织了培训会。研究人员观察到，所有医疗机构的AFS板均显示在可见的地方，Doti医院除外。尽管有些卫生工作者记得，以前的委员会都是青少年，但大多数HFOMC都没有青春期成员。一些卫生工作者提到学校，社区和同伴教育者对于与青少年接触并传递性健康和生殖健康信息至关重要。关键发现2：卫生机构已经向选定的FCHV，教师和其他人在乡村发展委员会中介绍了国家ASRH计划，并且卫生工作者认为社区意识是促进青少年获得SRH服务的关键因素。这项研究还研究了卫生工作者如何在ASRH计划中记录和报告数据，以及他们面临的困难。卫生工作者表示，他们通过参考不同的注册表来填写ASRH计划的每月报告表，并将数据与HMIS 32表一起发送。一些卫生工作者表示，他们很难保存记录，因为他们必须查看多个寄存器，并为ASRH计划提出了单独的记录格式。不定期报告似乎是一个问题，缺乏后续行动或进修培训也是如此。关于监测，卫生工作者报告说，GIZ / GFA工作人员与地区（公共）卫生部门的负责人一起参观了这些设施。采访中提到了资源有限的问题–该计划没有预算访问医疗机构。卫生工作者建议对地区进行年度审查，以使他们能够解决实施ASRH计划时遇到的困难和挑战。关键发现3：ASRH计划的记录和报告不是定期且一致的。卫生工作者提到该程序没有单独的记录寄存器，并建议将该程序包含在HMIS 32中（每月报告格式）。卫生工作者和青少年使用者之间的相互作用本研究研究了青少年获得卫生服务的机会以及卫生工作者在提供AFS时的行为。关于获得卫生服务的问题，卫生工作者说，青少年访问卫生设施主要是为了避孕药具以及其他性健康和生殖健康方面的问题。他们还提到，一些青少年对身体变化和外表感到担忧。卫生工作者一致认为，未婚青少年比已婚青少年访问医疗机构的次数更多，而男孩青少年比女孩更多。但是，该计划的需求方面很薄弱，只有很少的青少年报告说他们曾到一家医疗机构接受SRH服务。在访问过医疗机构的焦点小组讨论的参与者中，大多数人说他们访问该机构是为了携带避孕套。一些人与寻求服务以解决勃起问题和性器官周围皮疹的朋友走了。其他参与者说，他们从附近的医疗商店购买避孕套，而不是去医疗机构。多蒂（Doti）的大多数青春期女孩没有去过医疗机构，但在班克（Banke），青春期的女孩是去医院看病的，要么是为了自己，要么是陪伴朋友或sister子。青春期女孩因月经问题，口服避孕药和避孕套前往卫生设施；有些人的朋友曾到过医疗机构堕胎。已婚青少年报告前往医疗机构进行产前检查和接种疫苗。卫生工作者说，有时青春期的女孩会问起青春痘或性交时的止痛药。关于卫生工作者对青少年的行为，所有接受采访的卫生工作者都强调指出了X | |十一|自实施ASRH计划以来，他们的行为发生了变化。塞伊说，他们过去认为，让年轻人接触避孕药具会“破坏”或腐败他们，青少年不应谈论性健康和生殖健康或使用避孕药具。现在，有些人甚至说，青少年有权了解和使用现代计划生育方法。所有卫生工作者都强调，他们不询问寻求计划生育服务的青少年的婚姻状况。该研究发现，越来越多的人意识到SRH在卫生工作者中的重要性以及在隐私中处理SRH问题的必要性。这显然是卫生工作者意识到他们需要如何应对青少年的SRH需求。一些卫生工作者提到，高的病人流量意味着他们不能给青少年足够的时间。一些卫生工作者指出了有关ASRH特定方面的知识差距（例如紧急避孕），以及性传播感染），并建议进行培训将有助于该程序的技术方面以及其他方面的进修培训。这些评论和中央联络人的关注表明，卫生工作者需要更好的技能来应对青少年，并且可以对他们进行进一步的培训。向青少年询问了卫生工作者在访问医疗机构提供SRH服务时的反应。青春期男孩的经历参差不齐，但大多数人给出了积极的反馈，并说卫生工作者向他们提供了很好的建议并回答了他们的疑问。他们还分享说，他们可以很容易地从卫生设施中取出避孕套。许多参与者分享说，卫生工作者教他们如何正确使用安全套，并建议他们不要与多个伴侣进行无保护的性行为。青少年说，卫生工作者向他们保证，他们将保持机密和隐私。对等民族志的研究也表明，保持了机密性。虽然大多数青少年对医护人员的行为感到满意，并表示他们很乐意再次回到医疗机构，但其中一些人并没有很好的经历。一些青少年分享说，卫生工作者在去避孕套时询问他们是否结婚。一些青春期男孩提到，卫生工作者以一种挑逗的方式提出了这个问题，或者使他们变得“有趣”。同样，少女几乎无一例外地表示，她们发现卫生工作者的行为良好，而且卫生工作者以友好的方式与她们交谈。这些女孩还分享说，有单独的男女洗手间。他们指出，“姐妹”将他们带到单独的房间中来维护隐私。但是，Doti的一些青春期女孩不愿接受卫生工作者的行为。在某些情况下，卫生工作者具有判断力。医务人员的这种行为在青少年中产生了一种不信任感，使他们不愿去医疗机构和与医务人员讨论问题。关键发现4：所有卫生工作者表示，由于该计划，他们的行为发生了重大变化。他们与以前一样不愿向青少年提供避孕药具，因为他们认为这会“破坏”他们，并且他们以前认为青少年不应该谈论SRH或使用避孕药具。现在，当被问及对寻求SRH服务的青少年的行为变化时，几乎所有的卫生工作者都表达了对青少年的友好态度。但是，一位卫生工作者提到了对卫生工作者的培训方面的差距，中央一级的协调人也强调说，即，除了管理方面，这种培训还应涵盖有关性健康和生殖健康的更多技术知识和技能。主题以及有关性健康和生殖健康的青少年咨询。关键发现5：卫生工作者意识到在为青少年提供服务时保持隐私和确保机密性的重要性。他们提到在ANC诊所使用窗帘或与青少年会面，但病人流量过高有时使他们无法给青少年分配很多时间。关键发现6：很少有青少年表示他们曾去过医疗机构接受SRH服务。多数访问过的人都有相关的积极经历，而少数人则对卫生工作者的态度有不好的经历。据卫生工作者称，未婚青少年比已婚青少年访问医疗机构获得与ASRH计划相关的服务的机会更多。此外，青春期男孩比青春期女孩更多地访问卫生设施。同时，青春期的女孩往往对所提供的特定保健服务有详细的了解，例如，针对性传播感染，月经问题，痤疮，性交时的疼痛甚至流产。多数访问过医疗机构的青少年都表示，他们对医护人员的行为感到满意，并且医护人员以友好和乐于助人的方式对待他们，在提供信息和服务时不要求他们的婚姻状况并保持保密。被问到未去SRH服务的医疗机构的青少年被问及其原因。他们说，他们担心自己的问题会被谈论，并感到尴尬。这些青少年通常不知道医疗机构会私下提供保密服务。特别是男孩们说，他们感到不舒服，因为卫生工作者比他们高。青少年还分享说，在某些情况下，卫生工作者是亲戚，这会增加他们的不适感，因为他们感到害羞并且担心卫生工作者会告诉父母。他们还说，他们担心在医疗机构遇到邻居或认识的人。一些青少年说，由于到学校的距离很长，而且需要做家务，所以他们没有时间去看医疗机构。相反，他们与朋友或他们的母亲分享了他们的问题，因此，他们不认为需要去医疗机构。关键发现7：那些未使用SRH服务的青少年担心自己的机密性，这似乎是青少年不前往SHR服务的医疗机构的主要原因之一，除了让他们感到尴尬与那些比他们或熟人大。作为国家ASRH计划的一部分，已经制作了八本关于青少年SRH和权利问题的IEC小册子，并分发给了所有提供AFS的公共卫生机构以及这些机构集水区的学校。阅读手册的卫生工作者和青少年都发现这些材料非常有帮助。卫生工作者曾说过，青少年会去卫生机构阅读这些小册子。卫生工作者坚持认为，这些材料足以供青少年阅读和阅读，但不能广泛分发，除非在拜雅加布尔，那里的卫生工作者说他们一直在分发小册子。卫生工作者还说，他们已经将小册子分发给了学校图书馆和社区图书馆。除了小册子外，提供AFS的医疗机构还配有ASRH海报，ASSH流程图和漫画书。关键发现8：大多数接受采访的男孩都知道医疗机构提供的IEC材料，但是只有少数男孩和女孩说他们有

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