Final Report Survey 2
Multi-Year Annual Survey to Monitor Programme Effectiveness of the “Improving Reproductive Maternal and Newborn Health (IRMNH) Programme” Sierra Leone Study commissioned by UNFPA
July 15, 2016
Laarstraat 43, B-2840 Reet Belgium tel. +32-3-8445930 E-mail [email protected] fax. +32-3-8448221 www.hera.eu
Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone
hera - ULB - FOCUS 1000 / Draft Report Survey 2 / May 2016
Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone
Final Report Survey 2
Multi-Year Annual Survey to Monitor Programme Effectiveness of the “Improving Reproductive Maternal and Newborn Health (IRMNH) Programme” Sierra Leone
Consultant Team: Alexander, Sophie Dramaix, Michèle Fele, Dalia Jalloh, Mohamed Jalloh, Mohammad B Jan Franck Labat, Aline Medina, Marta (Team leader) Pratt, Samuel Sengeh, Paul Weber, Lilas Zhang, Weihong
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TABLE OF CONTENTS
Table of Contents ...... ii List of figures ...... v List of tables ...... v Acknowledgement...... viii List of abbreviations and acronyms ...... ix Summary ...... xi 1 Introduction ...... 1 1.1 Background ...... 1 1.2 Update on literature review ...... 1 1.2.1 Topics and methodology ...... 1 1.2.2 Family Planning ...... 2 1.2.3 Methodology of RH Surveys ...... 3 1.2.4 Effect of the EVD outbreak on health services in Sierra Leone ...... 3 1.3 Maternal and Newborn Health in Sierra Leone ...... 4 1.4 Fertility and Family Planning in Sierra Leone ...... 5 1.5 The Ebola Virus Disease outbreak and its impact on Maternal, Newborn and Reproductive Health Services ...... 6 1.6 Update on the IRMNH Programme ...... 6 2 Objectives and methodology of survey 2 ...... 8 2.1 Objectives ...... 8 2.2 Indicators to be monitored ...... 8 2.3 Survey components ...... 10 2.3.1 Household survey ...... 10 2.3.2 Health Facility Survey ...... 12 2.3.3 Focus Group Discussions ...... 12 2.4 Survey questionnaires ...... 13 2.5 Data collection ...... 13 2.5.1 Training of data enumerators, interviewers and supervisors ...... 13 2.5.2 Data collection ...... 14 2.5.3 Data management in the field ...... 15 2.5.4 Data analysis ...... 15 2.5.5 Ethical considerations ...... 17 3 Findings ...... 18 3.1 Characteristics of the population surveyed ...... 18 3.1.1 Heads of household interviews ...... 18 3.1.2 Individual interviews ...... 20
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3.1.3 Health facility survey ...... 24 3.1.4 Family Planning clients ...... 25 3.1.5 Family Planning service providers ...... 26 3.1.6 Participants in focus group discussions ...... 26 3.2 Adolescents and youth: sexuality and access to Family Planning services ...... 27 3.2.1 Sexuality and Family Planning ...... 27 3.2.2 Utilisation of health services ...... 36 3.2.3 Questions about payment: rationale and results ...... 38 3.2.4 Use of contraceptive methods during the EVD outbreak ...... 38 3.3 UNFPA interventions and adolescents and young population ...... 38 3.3.1 Saliwansai ...... 39 3.3.2 VPEs / attenuation – contamination of specificity of UNFPA interventions areas in survey 2 in comparison to survey 1 ...... 39 3.3.3 UNFPA and enhanced CAGS ...... 40 3.3.4 Comparing the two interventions (VPEs and “enhanced CAGs”) and change in time .. 40 3.4 The provision of FP services by the public health facilities ...... 43 3.4.1 Availability of contraceptive commodities at the health facilities on the day of the facility audit ...... 43 3.4.2 Without stock-outs of contraceptive commodities in the health facilities in the last six and three months ...... 43 3.4.3 Combination of Family Planning services being provided ...... 45 3.4.4 Equipment items ...... 45 3.4.5 Human resources for the provision of Family Planning services ...... 45 3.4.6 Management and logistics ...... 46 3.4.7 The Family Planning client – provider encounter...... 46 3.5 Adolescents and youth friendly services ...... 49 3.5.1 Standards for the provision of adolescent and youth friendly services ...... 49 3.5.2 Human resources for the provision of adolescents and youth friendly services ...... 50 3.5.3 Number of service delivery points (SDP) upgraded to provide "adolescent and youth friendly services” ...... 51 3.6 Focus group discussions ...... 51 3.6.1 Most common health/social problems affecting young people ...... 51 3.6.2 Age of sexual initiation for boys and girls, and how decisions are made to engage in sex 52 3.6.3 Knowledge and use of condoms ...... 53 3.6.4 Modern and traditional birth control methods...... 54 3.6.5 Engagement with partners/ parents on the decision to use Family Planning methods 55 3.6.6 Cost associated with getting Family Planning services ...... 55 3.6.7 Information regarding Family Planning and Reproductive Health ...... 56
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3.6.8 Health seeking practices and behaviours ...... 57 3.7 Outcome and output indicators ...... 58 3.7.1 Outcome indicators ...... 58 3.7.2 Output 1 indicators – demand creation ...... 64 3.7.3 Output 2 indicators - increased availability ...... 70 4 Discussion and conclusion ...... 72 4.1 Statement of principal findings ...... 72 4.1.1 Outcome indicators ...... 72 4.1.2 Output 1 (demand creation) indicators...... 73 4.1.3 Output 2 (increased availability) indicators ...... 73 4.2 Strengths and weaknesses of the study ...... 75 4.3 Comparing findings with other study results ...... 76 4.3.1 Outcome indicators ...... 76 4.3.2 Output-1 (demand creation) indicators ...... 77 4.3.3 Output-2 (increased availability) indicators ...... 77 4.4 Policy implications / unanswered questions and projection in the future ...... 77 4.4.1 Implications for conducting a next survey ...... 78 4.4.2 Policy and programme implications ...... 78 4.5 Conclusion ...... 79 ANNEXES ...... 1 Annex 1. List of surveyed health facilities ...... 1 Annex 2. Characteristics of respondents for the household survey ...... 4 Annex 3. Providers of Family Planning consultation by staff category and type of health facility, survey 2 ...... 6 Annex 4. Setting for the provision of Family Planning services by type of health facility, survey 2 ... 7 Annex 5. Availability of contraceptive methods on the day of the facility audit by type of health facility ...... 8 Annex 6a. Health facilities with no stock-outs of contraceptive in the last 6 months by type of health facility, survey 2 ...... 9 Annex 6b. Surveyed PHUS and hospitals with no stock-outs of contraceptives in the 6 and 3 months previous to the survey ...... 10 Annex 7. Equipment at health facilities ...... 11 Annex 8. Number counselling actions performed by type of provider. reported by observer ...... 12 Annex 9. List of staff involved in the survey ...... 13 Annex 10. Documentation available to the team ...... 15 Annex 11. Useful numbers, survey 1 and survey 2 ...... 18
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LIST OF FIGURES
Figure 1. Early childhood mortality rates in Sierra Leone 1999 - 2013...... 5 Figure 2. Time to reach closest health facility by transportation means (% of households) ...... 20 Figure 3. Time to reach the closest school by foot (% households) ...... 20 Figure 4. Age and sex distribution of young (10-24) interviewed in both surveys (%) ...... 21 Figure 5. Percentage of young people who cannot read, by age ...... 23 Figure 6. Proportion of young people who ever had a sexual relation, by age ...... 27 Figure 7. Condom use among boys/men and girls/ women (%) ...... 29 Figure 8. Comparison between survey 1 and survey 2 of motives for not using modern contraceptives, (% young 10-24 years non users, not pregnant and not attempting pregnancy and not fertility related) ...... 34 Figure 9. Opinion of young people 10-24 on the services received at health facilities (%) ...... 37 Figure 10. Young people 10-24 years saying the health services are youth friendly (%) (n=388) ...... 37 Figure 11. Paying for Family Planning services (%) (n=1409) ...... 38 Figure 12. Appreciation of the interviewees (10-24 years) on each of the interventions (%), survey 2 41 Figure 13. Influence of intervention on seeking Family Planning services, by sex (%), survey 2 ...... 41 Figure 14. Topics addressed by VPEs and CAGs (%), survey 2 ...... 42 Figure 15. Percentage of health facilities having at least one staff per category providing AYF services or trained on AYF services since the EVD outbreak, survey 2 ...... 51 Figure 16. Age – specific fertility rates (births per 1000 women) for Sierra Leone 2008-2013 ...... 76
LIST OF TABLES
Table 1. Summary of Survey 2 Results – Population Based Estimates – Year 2016 ...... xiii Table 2. Summary of Survey 2 Results – Sample Proportions Estimates – Year 2016 (*) ...... xvi Table 3. Results of literature search July 2014 to April 2016 ...... 2 Table 4. Sierra Leone - Maternal health indicators ...... 4 Table 5. Fertility and Family Planning indicators ...... 5 Table 6. Indicators to be monitored by Survey 2 IRMNH Programme ...... 9 Table 7. Selected chiefdoms, survey 2 IRMNH ...... 11 Table 8. Number of health facilities surveyed by type of health facility ...... 12 Table 9. Communities selected for focus group discussions ...... 13 Table 10. Number of enumerators, interviewers and supervisors trained ...... 14 Table 11. Number of households interviews by chiefdom – survey 2...... 18 Table 12. Household size and composition (n=1046/1172) ...... 19 Table 13. Household assets and sources of drinking water ...... 19 Table 14. Percentage in education or training by age and sex ...... 22 Table 15. Language spoken by respondents ...... 22 Table 16. Ability to read ...... 23 Table 17. Health facilities surveyed (n= 109)...... 24 Table 18. Infrastructure and service conditions for the provision of FP services ...... 24 Table 19. Characteristics of Family Planning clients (n=214) ...... 25 Table 20. Type of providers of Family Planning encounters observed ...... 26 Table 21. Number of participants in focus group discussion by age ...... 26 Table 22. Characteristics of participants in focus group discussions by age group ...... 27 Table 23. Sexual initiation (survey 1: n=1289; survey 2 n= 1407) ...... 27 Table 24. Negotiation of condom use / negotiation of not having sex, survey 1 and survey 2 ...... 28 Table 25. Negotiation of condom use / negotiation of not having sex , by age and sex,, survey 2 ...... 28 Table 26. Condom use, by sex, survey 1 and survey 2 ...... 29
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Table 27. Negotiation of condom use /negotiation of not having sex among young (10-24 yrs)who have met a VPE, survey 2 ...... 30 Table 28. Negotiation of condom use /negotiation of not having sex among young 10-24 yrs who have not met a VPE, survey 2 ...... 30 Table 29. Negotiation of condom use /negotiation of not having sex among young 10-24 yrs who have met a CAG, survey 2 ...... 31 Table 30. Negotiation of condom use /negotiation of not having sex among young 10-24 yrs who have not met a CAG, survey 2 ...... 32 Table 31. Distance to HF and use of modern methods, survey 1 and survey 2 ...... 33 Table 32. Modern contraceptive methods used (current users) ...... 33 Table 33. Knowledge and personal experience of STIs, survey 2...... 34 Table 34. Comparison of sexual activity frequency among young 10-24 years, by sex, survey 1 and survey 2 ...... 35 Table 35. Children and sexual activity by age (female only) ...... 36 Table 36. Health facility utilisation and reasons for using it among subjects who reported use of the health facility in the past year ...... 36 Table 37. Reasons for visiting the health facility, young people 10-24 years - 2016 ...... 37 Table 38. Loss of contrast between VPE+ and VPE- areas between survey 1 and survey 2 ...... 39 Table 39. Availability of contraceptive methods in the health facilities surveyed on the day of the visit ...... 43 Table 40. Percentage of health facilities without stock-out of contraceptives in the last six and three months ...... 44 Table 41. Percentage of health facilities with no-stock out of contraceptives in the last three months, 2016 and 2014 ...... 44 Table 42. Percentage of health facilities without stock-outs of modern methods of contraception in the last six months ...... 45 Table 43. Percentage of health facilities with at least one staff per category providing FP services or trained in LTM per staff category ...... 46 Table 44. Provider´s action during the counselling session, survey 2 ...... 47 Table 45. Percentage of FP users (clients) who were informed about the effects or problems of methods selected. for women 15-49 years (among new clients only), survey 2 ...... 47 Table 46. Percentage of FP users (clients) who were informed of both side effects of method selected or what to do in case of problems, for women 15-49 years (among new clients only), survey 1 and survey 2 ...... 48 Table 47. Percentage of providers who follow infection procedures, survey 2 ...... 48 Table 48. Existence of selected criteria for adolescents and youth friendly services, survey 2 ...... 49 Table 49. PHU having at least one member of staff trained in youth friendly services, survey 1 and 2 50 Table 50. Percentage of health facilities with at least one staff per category providing services for adolescents and young people or trained in adolescents and youth friendly services, survey 2 ...... 50 Table 51. PHU upgraded to provide youth friendly services ...... 51 Table 52. Fertility rate among female 10-24 years by age and survey ...... 59 Table 53. Contraceptive prevalence of modern methods if in a union or married, by age and sex, survey 2 ...... 59 Table 54. Difference in population estimates of contraceptive prevalence of modern methods among those in a union or married, by sex and survey ...... 60 Table 55. Unmet need for FP among female in a union, by survey and by age for survey 2 ...... 60 Table 56. Unmet need for FP among female 10-24 who are sexually active, by survey and by age for survey 2 ...... 61 Table 57. Difference 2014 -2016: unmet need for Family Planning for female in union or married, ... 61 Table 58. Difference between survey 1 and survey 2: female pregnancy rate, by age group ...... 61 Table 59. Condom use at last sex, by sex and age, comparison with survey 1 ...... 62 Table 60. Difference between survey 1 and survey 2: condom use at last sex by sex ...... 62
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Table 61. Condom use at last sex, by sex,” in/out of school” 2016 and 2014, population estimates .. 62 Table 62. Condom use at last sexual intercourse, by sex and literacy, comparison with survey 1 ...... 63 Table 63. Difference between survey 1 and survey 2: condom use at last sexual intercourse by literacy ...... 63 Table 64 Consistent condom use as a % of users at last sex by sex and age, Survey 2 and survey 1, population estimates ...... 63 Table 65. Consistent condom use, as a % of users at last sexual intercourse, by sex and literacy, Survey 2 and survey 1, population estimates...... 63 Table 66. Condom use according to having met a VPE, by age groups and survey ...... 64 Table 67. Meeting a VPE in the past year, by sex and survey ...... 64 Table 68. Young reporting VPE influencing them to attend a health facility in the past year, by sex and survey ...... 64 Table 69. Percentage Family Planning clients reporting interaction with VPE ...... 65 Table 70. Percentage of health facilities being linked to a CAG and percentage of health facilities keeping records of CAGs referrals ...... 65 Table 71. Difference between survey 1 and survey 2: young (10 -24) meeting a CAG in the past year, by sex ...... 66 Table 72. Difference between survey 1 and survey 2: CAG influences to go to the health facility, by sex ...... 66 Table 73. CAG referral to go to the health facility, females by age category ...... 66 Table 74. Family Planning clients referred by a CAGs ...... 67 Table 75. Percentage of female Family Planning clients under 19 years who visited a health facility and reported that they were referred by the CAG in the past year, survey 1 and survey 2 ...... 67 Table 76. Percentage of Family Planning clients who mentioned interaction with a CAG influencing them to attend a health facility today, survey 2 ...... 68 Table 77. Percentage of girls 10 -19 years referred by CAGs to the health facility, survey 2 ...... 68 Table 78. Having heard of modern Family Planning method, by the number of methods and sex ...... 68 Table 79. Difference survey 1 and survey 2:Young people who have heard of at least one modern Family Planning method, by sex ...... 69 Table 80. Source of information for SRH ...... 69 Table 81. Percentage of new acceptors of contraceptive methods, among Family Planning clients interviewed (10-24 years of age) by method accepted, survey 2 ...... 70 Table 82. Percentage of surveyed SDP with long acting Family Planning methods available on the day of the visit, survey 2 ...... 70 Table 83. Percentage of young (10 -24 years) who think that the health services are not youth friendly, survey 2 ...... 71 Table 84. Percentage of Family Planning clients who think this facility is youth friendly, survey 2 ...... 71 Table 85. Difference survey 1 and survey 2: Young (10-24) who have used the health facility in the past year, by sex ...... 71
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ACKNOWLEDGEMENT
We are grateful to the heads of household and young people who responded patiently to our questions, to the Family Planning clients who agreed to be interviewed and observed, to the health staff whose Family Planning counselling sessions we were allowed to observe, and the health facility managers (In-charges) who answered our questions about service availability and quality and who supported the work of our data collectors. Their collaboration made it possible for us to collect the information presented in this report.
We also acknowledge with appreciation the advice and logistic support of the Ministry of Health and Sanitation and the District Health Management Teams in Kenema, Kono, Kambia, Koinadugu, Bonthe, Moyamba, Kailahun and Pujehun.
We are also grateful to the survey enumerators, field supervisors, focus group facilitators, note- takers, and drivers whose commitment was key in achieving our targets, and to the staff at FOCUS 1000 office in Freetown and hera in Reet who provided valuable backup.
The Consultant Team Reet, July 2016
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LIST OF ABBREVIATIONS AND ACRONYMS
AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care AYFS Adolescents and Youth-Friendly Services BCC Behaviour Change and Communication BMJ British Medical Journal BPEHS Basic Package of Essential Health Services CAG /CAGs Community Wellness Advocacy Groups CHC Community Health Centre CHO Community Health Officer CHP Community Health Post CHW Community Health Worker CI Confidence Interval CPR Contraceptive Prevalence Rate DFID UK AID Department for International Development, United Kingdom DHS Demographic Health Survey EA 2004 Census Enumeration Areas EVD Ebola Virus Disease FGD Focus Group Discussion FHCI Free Health Care Initiative FP Family Planning HF Health Facility HFS Health Facility Survey HH Household HHS Household Survey HIV Human Immunodeficiency Virus IEC Information Education and Communication IQR Interquartile range IRMNH Improving Reproductive Maternal and Newborn Health Programme IUD Intrauterine Device LARC Long Acting Reversible Contraception LF Logical Framework LLITN Long Lasting Insecticide Treated Net LMIC Low and Middle Income Countries M&E Monitoring and Evaluation MCH Maternal and Child Health MCHP Maternal and Child Health Post
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MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Ratio MNCH Maternal, Newborn and Child Health MNH Maternal and Newborn Health MoHS Ministry of Health and Sanitation, Sierra Leone MSSL Marie Stopes Sierra Leone MSWGCA Ministry of Social Welfare, Gender and Children Affairs NEJM New England Journal of Medicine NHSS National Health Sector Strategy PHU Peripheral Health Unit PMEL Partnership Management, Evaluation and Learning PMTCT Prevention of Mother to Child Transmission (of HIV) PNC Post Natal Care PPS Probability Proportional to Size PSU Primary Sampling Units QIQ Quick Investigation of Quality QoC Quality of Care RCT Randomised Controlled Trial RD Restless Development RMNH Reproductive Maternal and Neonatal Health RN Registered Nurse RNCH Reproductive Newborn and Child Health SBA Skilled Birth Attendant SDP Service Delivery Point SECHN State Enrolled Community Health Nurse SL DHS Sierra Leone Demographic Health Survey SL MICS Sierra Leone Multiple Indicator Cluster Survey SRH Sexual and Reproductive Health STI Sexually Transmitted Infections TBA Traditional Birth Attendant U5MR Under Five Mortality Rate ULB-ESP Université Libre de Bruxelles – Ecole de Santé Publique UNFPA United Nations Population Fund UNICEF United Nations Children´s Fund VPE Volunteer Peer Educator WHO World Health Organisation
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SUMMARY
This is the second survey report (survey 2, conducted in 2016) in a planned series of three surveys. Like the first report (survey 1, baseline, conducted in 2014), it has been established by the Consortium hera/ULB-ESP/FOCUS 1000 (led by hera). UNFPA commissioned the team to establish a baseline and to monitor the effectiveness of UNFPA interventions under the DFID/UK AID supported “Improving Reproductive Maternal and Newborn Health Programme (IRMNH) in Sierra Leone”.
The specific objectives of this assignment are: i) monitoring the effectiveness of demand-side interventions implemented by UNFPA under the IRMNH programme, particularly the placement of Volunteer Peer Educators (VPEs), the establishment of an enhanced programme for Community Wellness Advocacy Groups (CAGs) and the broadcasting of the Saliwansai radio programme (not active during year 2015, and hence not assessed in this report) ; ii) monitoring the availability and uptake of modern Family Planning services among young males and females 10 -24 years of age with a specific training activity on long acting reversible contraception (LARC) and iii) monitoring the Quality of Care for the provision of Family Planning services at public health facilities, and the upgrading of health facilities and specific training to provide Adolescent and Youth Friendly Services.
The initial plan was to perform three successive monitoring surveys / focus groups to be implemented over a two-year (month 1, month 13, month 25) period to assess progress on selected output and outcome indicators. The first (baseline) survey had been conducted in May / June 2014. However, the outbreak of Ebola Virus Disease (EVD) in Sierra Leone delayed the second set of monitoring activities. This second report pertains therefore to surveys and focus groups performed in 2016, after WHO declared the outbreak period ended. Despite the deep disruption brought on by the EVD outbreak, it was considered important to perform, albeit after two years and an EVD outbreak, the situation in relation to the UNFPA component of the IRMNH programme.
As in the 1st report, chapter one briefly describes the programme. The methodology of the surveys and the focus groups are outlined in chapter two. Chapter three presents the findings of the surveys and focus groups. The conclusions and policy implications are presented in chapter four.
The 2016 IRMNH assessment (survey 2) was conducted along three major axes:
A household survey of the effectiveness of demand-side interventions for young people (10- 24). It collected data on the need for and use of Family Planning and Reproductive Health services, as well as information on the two of the three main UNFPA interventions at the community level (i.e. VPEs and enhanced CAGs). The 3d intervention (Saliwansai radio programme did not occur during 2015, and was therefore not included). It included interviews to 1172 heads of households, of which 1046 were eligible, because there were young people eligible in the household. They were interviewed on general characteristics of the household. The full interviews were performed with 1409 women/girls and men/boys aged 10-24. The households were located in 12 chiefdoms in six districts of three provinces (North, South, and East). A health facility survey to assess Quality of Care (QoC) using an adaptation of the MEASURE Evaluation tools for Quick Investigation of Quality (QIQ) in Family Planning Programmes1 to gather information on indicators of quality care and provision of youth friendly services.
1 MEASURE EVALUATION 2001. Quick Investigation of Quality (QIQ) A User's Guide for Monitoring Quality of Care in Family Planning. MEASURE Evaluation Manual Series, No. 2. MEASURE Evaluation.
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Information was collected in 109 health facilities located in 62 chiefdoms in 8 districts. A total of matched 214 client-provider Family Planning encounters and 214 client exit interviews were included in the analyses. The care-giver in charge was interviewed in each health facility. A qualitative study of barriers to accessing reproductive health services based on 17 focus group discussions with young people aged 10-24 years.
This survey generated follow-up values for programme indicators with the aim to contribute to knowledge and understanding of the Sexual and Reproductive Health needs of young people in Sierra Leone. A summary of survey 2 results are presented in table 1 and table 2. Table 1 presents selected population based estimates. Table 2 presents sample based proportions.
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Table 1. Summary of Survey 2 Results – Population Based Estimates – Year 2016 OUTCOME: INCREASED UTILISATION OF QUALITY FAMILY PLANNING, REPRODUCTIVE MATERNAL AND NEW-BORN HEALTH SERVICES WITH FOCUS ON YOUNG PEOPLE Age-specific fertility rate / 1000 for the year 2016* 10 - 14 yrs 6.1/1000 15 - 19 yrs 147.4/1000 20 - 24 yrs 305.6/1000 10 - 24 yrs 124.2/1000 Contraceptive prevalence rate (% girls/women 10-24 who are currently using modern contraceptive methods) if in union or married % 95% CI Modern methods (10-24 yrs) 34.0% 21.7;46.2 Unmet need for Family Planning among girls/women aged 10-24 % 95% CI Unmet need of females 10-24 married or in a union 31.4% 23.1;41.0 Unmet need of sexually active females 10-24 23.9% 12.8;40.0 OUTPUT 1: INCREASED KNOWLEDGE OF INTEGRATED RMNH SERVICES IN WOMEN AND YOUNG PEOPLE (DEMAND CREATION) Information, education, communication, knowledge and practices Percentage of young people (10-24) who used condoms the last time they had sexual intercourse disaggregated by age, sex, and education
Male Female Total % 95% CI % 95% CI % 95% CI 10-14 yrs 20.8% 2.3;74.3 23.2% 9.7;45.9 22.4% 7.0;52.9 15-19 yrs 25.8% 12.9;45.0 7.8% 3.4;16.9 13.1% 6.8;23.7 20-24 yrs 44.6% 34.9;54.7 9.2% 1.9;33.9 21.1% 8.3;43.9 10-24 yrs 35.1% 24.7;47.2 9.3% 4.1;19.7 17.5% 9.2;30.6
Can read 42.2% 24.8;61.7 13.6% 5.7;29.2 24.6% 11.8;44.3 Can not read 7.3% 0.4;60.8 3.4% 1.4;8.0 4.1% 1.4;11.5 All 35.1% 24.7;47.2 9.3% 4.1;19.7 17.5% 9.2;30.6 Percentage of young people 10-24 with consistent condom use in the past year among all who reported condom use at last sex, by sex and age Male Female Total % 95% CI % 95% CI % 95% CI 10 - 14 yrs 100.0% / 100.0% / 100.0% / 15 - 19 yrs 73.6% 54.2;86.8 74.0% 53.4;87.5 73.8% 56.5;85.9 20 - 24 yrs 63.0% 26.3;89.0 78.0% 17.2;98.4 67.5% 25.1;92.8 10 - 24 yrs 67.9% 43.3;85.4 79.6% 53.5;93.0 72.3% 48.4;87.9 Percentage of young 10-24 who ever heard of a modern Family Planning method Male Female Total % 95% CI % 95% CI % 95% CI Has not heard of any method 36.2% 29.5;43.5 24.0% 16.7;33.3 29.0% 24.9;33.6 Heard of at least one method 63.8% 56.5;70.5 76.0% 66.7;83.3 71.0% 66.4;75.1 Percentage of young 10-24 who ever heard of a modern Family Planning method (by number of methods heard) Male Female Total % 95% CI % 95% CI % 95% CI 1 method 7.3% 5.8;9.1 4.8% 3.5;6.7 5.8% 4.7;7.2 2 methods 4.8% 2.9;7.8 3.8% 2.2;6.5 4.2% 2.6;6.8 3 methods 7.1% 5.0;10.1 7.4% 5.8;9.6 7.3% 5.8;9.1 4 methods 16.0% 13.2;19.3 19.3% 15.6;23.6 17.9% 15.9;20.2 5 methods 9.0% 5.7;16.0 11.3% 9.1;14.0 10.6% 8.7;12.9 6 methods 5.8% 3.2;10.3 10.3% 8.2;12.9 8.5% 6.9;10.4 7 methods 5.9% 4.5;7.9 5.3% 2.6;10.5 5.6% 3.9;7.9
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8 methods 4.0% 2.9;7.2 6.0% 4.5;8.0 5.4% 4.1;7.1 9 methods 2.6% 1.3;5.4 7.7% 3.2;17.2 5.6% 3.1;10.0 Source of information for SRH among young 10 -24 yrs (percentage who reported each source as source of information for SRH) % 95% CI % 95% CI School 38.8% 30.5;47.9 VPE 19.0% 12.1;28.6 Parents 14.8% 11.6;18.8 CAG 5.1% 3.6;7.3 27.5;37.9 I don’t need this 10.6% 4.3;24.2 Friends 32.5% information Health structures 25.7% 17.3;36.4 I don’t know 16.4 % 10.1;25.6 Community health workers 19.7% 9.0;37.9 Internet 0.8% 0.3;1.9 Volunteer peer educators (VPE) Percentage of adolescents (10-19 yrs) who have met a VPE who reported using a condom last time they had sexual intercourse (denominator is all young who had sex according to meet VPE or not) % 95% CI Has met a VPE 12.9% 5.2;20.7
Has not met a VPE 15.5% 6.3;24.7 Percentage young people (10-24 yrs) reporting meeting a VPE in last year, by age Male Female Total % 95% CI % 95% CI % 95% CI 10 - 14 yrs 50.3% 29.7;70.9 43.2% 17.2;73.7 46.6% 22.9;71.9 15 - 19 yrs 58.7% 33.1;80.4 52.5% 24.5;79.1 54.8% 28.4;78.8 20 - 24 yrs 53.9% 41.4;65.9 34.8% 18.8;55.1 41.4% 30.1;53.6 10 - 24 yrs 53.4% 35.1;70.8 44.3% 20.5;71.0 48.0% 26.5;70.3 Percentage of young people (10-24 yrs) reporting VPE influencing them to attend a health facility (among those who have met a VPE and who have been to the facility in the past year) Male Female Total % 95% CI % 95% CI % 95% CI 10 - 14 yrs 50.3% 28,3;72,1 41.8% 9.5;83.0 46.5% 19.3;76.0 15 - 19 yrs 81.6% 19.6;98.8 65.5% 20.6;93.3 69.3% 28.7;92.7 20 - 24 yrs 83.8% 34.0;98.1 72.5% 21.7;96.1 76.7% 23.9;97.2 10 - 24 yrs 71.1% 36.1;91.5 64.1% 19.2;93,0 66.6% 24.4;92.5 Community wellness advocacy groups (CAG) Percentage of young people (10-24 yrs) who reported meeting a CAG in the past year, by age and sex (HH survey) Male Female Total % 95% CI % 95% CI % 95% CI 10 - 14 yrs 9.4% 4.0;21.2 14.2% 10.0;19.8 12.0% 7.5;18.7 15 - 19 yrs 16.3% 7.0;33.6 33.3% 24.8;43.0 26.9% 18.3;37.8 20 - 24 yrs 26.6% 17.9;37.8 48.7% 35.7;61.8 41.2% 28.9;54.7 10 - 24 yrs 14.7% 7.7;26.1 29.2% 22.8;36.5 23.3% 16.8;31.3 Percentage of young people (10-24 yrs) who have met a CAG, being referred by them to a health facility in the past year (among those who have met a CAG and went to the facility) by sex (HHS) Male Female Total % 95% CI % 95% CI % 95% CI 10 - 24 yrs 14.9% 3.7;44.3 6.7% 2.0;20.0 8.4% 3.3;19.7
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Percentage of females (10-24 yrs) who have met CAGs being referred by them to a health facility in the past year, by age (among those who have met a CAG and went to the facility) (HHS) Female (%) 95% CI 10 - 14 yrs 0.0% /
15 - 19 yrs 4.7% 1.4;15.0
20 - 24 yrs 9.7% 2.2;33.5
10 - 24 yrs 6.7% 2.0;20.0 Percentage of girls 10 – 19 yrs who were referred to the health facility by a CAG in the past year (denominator includes all girls under 19, whether they have met a CAG or not, 1.0% 0;2.6 Referrals for any ailment or health condition. Adjusted for survey design Percentage of girls 10 – 19 yrs who were referred to the health facility by a CAG in the past year (denominator includes all girls who have met a CAG and who answered the question about being 4.6% 0;10.2 referred. Adjusted for survey design Percentage of girls 10 – 19 yrs who visited a public health facility who reported that they were referred by a CAG in the past year (denominator includes all girls who have met a CAG and who reported having 3.7% 0;7.9 visited the health facility in the past year). Adjusted for survey design Percentage of girls 10 – 19 yrs who visited a public health facility who reported that they were referred by a CAG in the past year (denominator includes all girls 10-19 yrs who went to the health facility in the past 1.5% 0;3.2 year, whether they have met a CAG or not. Adjusted for survey design OUTPUT 2: INCREASED AVAILABILITY AND UPTAKE OF MODERN FAMILY PLANNING COMMODITIES AND STI SERVICES Adolescent and Youth Friendly Services
Percentage of young people (10-24 yrs) considering that health services are not youth-friendly (not youth-friendly: “little or not at all")
Male Female Total % 95% CI % 95% CI % 95% CI 10 - 24 yrs 3.1% 0,6;15,1 2.3% 0,6;8,7 2.5% 0,6;9,9 Note: *It is a rate but can be applied to the total population More detailed results and number of observations can be found in the report.
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Table 2. Summary of Survey 2 Results – Sample Proportions Estimates – Year 2016 (*)
OUTCOME: INCREASED UTILISATION OF QUALITY FAMILY PLANNING, REPRODUCTIVE MATERNAL AND NEW-BORN HEALTH SERVICES WITH FOCUS ON YOUNG PEOPLE Age-specific fertility rate / 1000, year 2016 (HHS) 10 - 14 yrs 6.1/1000 15 - 19 yrs 147.4/1000 20 - 24 yrs 305.6/1000 10 - 24 yrs 124.2/1000 Contraceptive prevalence rate (% girls/women 10-24 who are currently using modern contraceptive methods) if in union or married (HHS) Modern methods (10-24 yrs) 30.1%
Unmet need for Family Planning among (HHS) girls/women aged 10-24 Unmet need of females 10-24 married or in a union 29.7x% Unmet need of sexually active females 10-24 27.6x% Proportion of pregnant females (10-24) among those who already had sex, by age category (HHS) 10 - 14 yrs 0.0% 15 - 19 yrs 10.6% 20 - 24 yrs 7.2% 10-19 yrs 9.4% 10-24 yrs 8.4% OUTPUT 1: INCREASED KNOWLEDGE OF INTEGRATED RMNH SERVICES IN WOMEN AND YOUNG PEOPLE (DEMAND CREATION) Volunteer peer educator (VPE) Percentage of young people (10-24) who used condoms the last time they had sexual intercourse disaggregated by age, sex, and education((HHS) Male Female Total (%) Male Female Total (%)
(%) (%) (%) (%) Can read 33.5 12.7 33.5% 10-14 yrs 20.0 15.4 17.1 15.6 Cannot 6.7 3.8 4.4% 15-19 yrs 24.5 10.7 read 20-24 yrs 32.3 6.2 15.1 10-24 yrs 27.7% 8.9 15.5 Percentage young people (10-24 yrs) reporting meeting a VPE in last year (HHS) Male Female (%) Total (%)
(%) 10-24 yrs 46.0% 43.3% 44.6% Percentage of adolescents (10-19 yrs) who have met a VPE who reported using a condom the last time they had a sexual intercourse (including all young, whether they 4.9% had sex or not) (25/511) (HHS) Percentage of Family Planning facility users (clients) interviewed reporting meeting a 30.8% VPE last year 65/211(HFS) Percentage of Family Planning facility users (clients) interviewed who reported VPE interaction having influence them to visit the health facility today for family planning 76.9% services (among those that have met a VPE) 50/65 (HFS) Community Wellness Advocacy Groups Percentage of surveyed health facilities being linked to a CAG ( n=109) (HFS) 85.0%
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Percentage of surveyed health facilities keeping records of CAGs referrals, among those 51.6 % being linked to a CAG). 48/93). (HFS) Percentage of Family Planning clients (12-45 yrs) reporting meeting a CAG in the past 64.0% year (135/211) (HFS) Percentage of Family Planning clients (12-45 yrs) reporting referred by a CAG in the 63.7% past year. Among those that have met a CAG (86/135) (HFS) Percentage of adolescents girls (under 19 yrs) who visited a health facility who 7.3% reported that they were referred by a CAG in the past year (4/55). (HHS) Percentage of Family Planning clients under 19 yrs. who visited a health facility and reported that they were referred by a CAG in the past year. Among those having met a 57.9% CAG (11/19) ( from HFS) Percentage of Family Planning clients 12-45 who mention interaction with CAG may 90.3% have influenced them to attend a health facility in the past year (122/135) (HFS) Percentage of girls 10 – 19 yrs who were referred to the health facility by a CAG in the past year (denominator includes all girls under 19, whether they have met a CAG or 1.3% not,( 8/577). Referrals for any ailment or health condition. (HHS) Percentage of girls 10 – 19 yrs who were referred to the health facility by a CAG in the past year (denominator includes all girls who have met a CAG and who answered the 6.6% question about being referred, (8/121) (HHS) Percentage of girls 10 – 19 yrs who visited a public health facility who reported that they were referred by a CAG in the past year (denominator includes all girls who have 6.7% met a CAG and who reported having visited the health facility in the past year, (4/59 ). (HHS) Percentage of girls 10 – 19 yrs who visited a public health facility who reported that they were referred by a CAG in the past year (denominator includes all girls 10-19 yrs 2.4% who went to the health facility in the past year, whether they have met a CAG or not, 4/163). (HHS) Percentage of young people (10-24) who have met a CAG in the past year, by age, by sex. (HHS) By age 10 - 14 yrs 10.0% 15 - 19 yrs 25.8% 20 - 24 yrs 40.9% 21.5% By sex Male Female 10 - 14 yrs 7.3% 12.7% 15 - 19 yrs 18.5% 32.2% 20 - 24 yrs 20.2% 52.2% 10-24 yrs 13.1% 28.6% Develop IEC/BCC materials on FP/STI Percentage of girls/women who have heard of more than one method of modern family planning by age (HHS) 10 - 14 yrs 42.6% 15 - 19 yrs 90.0% 20 - 24 yrs 97.8% 10-24 yrs 71.5% Source of information for SRH among young people 10 -24 yrs (HHS) School 34.9% VPE 18.9% Parents 12.5% CAG 4.5%
Friends 34.0% Internet 0.3% Health structure 21.2% Other 4.1%
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Community Health 24.2% Don´t need this information 12.6% Worker OUTPUT 2: INCREASED AVAILABILITY AND UPTAKE OF MODERN FAMILY PLANNING COMMODITIES AND STI SERVICES Delivery of Family Planning services Percentage of new young acceptors of contraceptives (10-24) disaggregated by age and method. It was calculated for the Family Planning clients (new acceptors) who were interviewed at the health facility (HFS). n % Acceptors new to contraception aged 12-24 29 32.2% (n=90) Distribution by contraceptives method Pill 7 38.9% (n=18) Injectable 6 33.3% Imlant (Captain Band) 5 27.8% Condom 0 0.0% Number and percentage of surveyed government PHUs and hospitals with no stock-outs of contraceptives in the last 6 months (all types facilities). (HFS) n % n % n % Combined oral pill (n=109) 84 77.1% IUD 45 41.3% Spermicide 0 0.0% (n=109) (n=109) Progesterone only pill (n=109) 10 96.3% Implant 62 56.9% Female 5 4.6% 5 (n=109) sterilisation (n=109) Combined Injectable (n=109) 96 88.1% Male 103 94.5% Vasectomy 3 2.8% Condom (n=109) (n=109) Progesterone-only injectable (n=109) 4 3.7% Female 69 63.3% condom (n=109) Number and percentage of surveyed government PHUs and hospitals with no stock-outs of contraceptives in the last 3 months (all types facilities)(sample proportion from HFS) n % n % n % Combined oral pill (n=109) 93 85.3% IUD 46 42.2% Spermicide 0 0.0% (n=109) (n=109) Progesterone only pill (n=109) 104 95.4% Implant 75 68.8% Female 4 3.7% (n=109) sterilisation (n=109) Combined Injectable (n=109) 104 95.4% Male 105 96.3% Vasectomy 3 2.8% Condom (n=109) (n=109) Progesterone-only injectable (n=109) 4 3.7% Female 70 64.2% condom (n=109) Number and percentage of surveyed government PHUs and hospitals with no stock-outs of modern methods of contraception (excluding female sterilisation. vasectory and 100.0% progestin-only injectables) in the last 6 months ( n=109, all types facilities). ( HFS) Number and percentage of surveyed government PHUs and hospitals with no stock-outs of modern methods of 100.0% contraception (excluding female sterilisation. vasectory and progestin-only injectables) in the last 3 months (n= 109, all types facilities). (HFS) Number and Percentage of Service Delivery Points (all types of health facilities) with long acting Family Planning methods (IUD and implants) available on the day of the visit (N=109) (sample proportion from HFS) n % IUD (n=109) 46 42.2% Implant (n=109) 81 74.3%
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Adolescent and Youth Friendly Services
Number and Percentage of SDPs upgraded to provide Adolescent and Youth Friendly services (**)(sample proportion from HFS) n % n % Community All facilities (n=110) 33 30.3% Health Posts 14 42.4% (n=36) Maternal and Child Hospitals (n=9) 1 3.0% 0 0.0% Health Posts (n=19)
Community Health Centres (n=45) 18 54.5%
Percentage of young people (10-24 yrs) considering that health services are not youth-friendly (not youth-friendly: 1.6% “little or not at all") (HHS) Percentage of adolescents (10-19) who have met VPE who reported using condom last time they had a sexual 14.9% intercourse (denominator all young 10-19 who have met a VPE and answered to the question of using condom) Quality of Care Percentage of FP users (clients) who were informed about side effects or problems of methods used (among new clients only)(HFS) As reported by client As observed Explains how to use selected 96.2% 96.8% method Explains side effects of method 91.1% 94.52% selected Explains what to do in case of 94.9% problems Percentage of FP users (clients 15-49) who were informed both about side effects of method As reported by client selected and what to do in case of problems 77.7 % (73/94) (HFS) Percentage of FP clients/users who are satisfied (perception) by services received (HFS) > 90% of the clients felt comfortable to ask questions > 90% thought that the amount of information provided during the session was good or very good
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Percentage of FP providers who demonstrate good counselling skills (all Family Planning clients. as
observed) (from HFS) n % n % Encourage client to ask Use visual aids (n=214) 45 21.0% 209 97.7% questions (n=214) Assure confidentiality Use client record (n=214) 201 93.9% 159 74.3% (n=214) Ask open ended questions (n=214) 209 97.7% Discuss a return visit (n=214) 212 99.1% Ask client her concerns with any Treat client with respect 193 93.9% 213 99.5% method (n=214) (n=214) Information not discussed(HFS) History of pregnancy complications Number of living children 184 86.0% 99 66.3% (n=214) (n=214) History/signs/symptoms of Timing of next child (n=214) 150 70.1% 138 64.5% STIs (n=214) Multiple/single sexual partner(s) Current pregnancy status 178 73.2% 73 34.1% (n=214) (n=214) Marital / relationship status Desire for more children (n=214) 137 64.0% 63 29.4% (n=214) Partner´s attitude to FP HIV/AIDS and STIs discussed 46.7% 122 57.0% 100 (approve/disapprove) (n=214) (n=214)
Percentage of providers who follow infection prevention procedures (as observed) (HFS)
Injection (n=93) n % Pelvic exam (n=11) N % Wash hands before injection 79 84.9% Washing hands 11 100.0% Use a disposable autodestruct syringe Put on new or disinfected 92 98% 11 100.0% and needle gloves Use sterilised or high-level Drop needle into a safety box 42 45.2% 11 100.0% disinfected instruments Ensure that instruments and reusable gloves are 11 100.0% decontaminated
Number and percentage of (visited) facilities that had at least one member of staff trained in Adolescent and Youth-Friendly services (N=109) (HFS) n % n n Community All facilities 49 45.0% Health Posts 20 40.8% (n= 36) Maternal and Child Hospitals (n=9) 6 12.2% 1 2.0% Health Posts (n=19) (*) The table presents the results corresponding to the agreed indicators to be monitored (see table 5 in the report) plus additional calculations requested by UNFPA (**)Composite of 3 criteria: i) having at least one trained health worker in adolescents and youth SRH. ii) privacy and confidentiality honoured and iii) education material available onsite Note: More detailed results and number of observations can be found in the report.
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1 INTRODUCTION
1.1 Background
DfID (UK AID) is providing financial assistance over four years (2012/13 to 2015/16) to support the implementation of the “Improving Reproductive, Maternal and Newborn Health (IRMNH) Programme in Sierra Leone”. The goal is to contribute to the accelerated reduction of maternal and neonatal mortality and morbidity through scaling up demand for increased utilisation of Family Planning (FP) and other related Reproductive Health (RH) services for women of childbearing age, men and young people in the country. The programme implementation brings under a single framework major players in the health sector, including the Ministry of Health and Sanitation (MoHS), the Ministry of Social Welfare Gender and Children Affairs (MSWCHA), UNFPA, UNICEF and Marie Stopes Sierra Leone.
The Consortium hera/ULB-ESP/FOCUS 1000 (lead by hera) has been commissioned by UNFPA to establish a baseline and monitor the effectiveness of UNFPA interventions under the UK AID supported IRMNH programme. The monitoring efforts include conducting three surveys with the same methodological and technical requirements over the period 2014 - 2015. Survey 12 (baseline survey) was conducted in May-June 2014. This document presents the findings of Survey 2 conducted in January – February 20163.
1.2 Update on literature review
1.2.1 Topics and methodology The initial literature search was performed for the period from July 2013 to July 2014; for the second survey it was updated from July 2014 to April 2016. The same topics were considered relevant as for the baseline survey:
Family Planning services o In low and middle income countries (LMICs) / in young people o Acceptance / observance / discontinuation o Behavioural strategies Methodology of reproductive health (RH) surveys in low and middle income countries (LMICs) limited to o Indicators and in particular discussions on the concept of “unmet need” o Utilisation and validity of electronic tools Health in Sierra Leone This last topic was replaced, because of the Ebola virus disease (EVD) outbreak by: Effect of the EVD outbreak on health services
The main focus was on publications with a high level of evidence such as Cochrane reviews. New reviews were also included.
2 hera/ULB/ESP/FOCUS 1000. Final Report Survey 1. Multi-Year Annual Survey to Monitor Programme Effectiveness of the “Improving Reproductive Maternal and Newborn Health (IRMNH) Programme”.Sierra Leone. Study commissioned by UNFPA. December 9, 2014. 3 Survey 2 was originally planned to take place in 2015. Its implementation was delayed due to the ebola virus disease outbreak that affected the country in the period mid-May 2014 – mid 2015.
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1.2.2 Family Planning Search strategy: {“contracept*” AND “services OR utilisation” AND “evidence OR Cochrane”}. This strategy retrieved 111 publications, of which 4 were relevant Cochrane systematic reviews. These are summarised in table 3.
Table 3. Results of literature search July 2014 to April 2016
1st author and year Title n studies Comments Conclusion Lopez et al. 20164 Brief educational Cochrane Heterogeneity / Evidence of strategies for Systematic none in sub- effectiveness improving contraception Review 11 Saharan Africa use in young people randomised control trials (RCT) Dalaba et al. 20165 Effect of a community- 1 qualitative Multiple Effective based primary health study of components care attitudinal programme on change reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana Behavioural interventions for improving condom use for dual protection Sarkar et al. 20156 Community 1 study Includes data from Effective on based reproductive Sierra Leone (SL) utilisation and on health interventions for and age 10-24 pregnancy young married couples occurrence in resource-constrained settings: a systematic review.
Oringanje et a. Interventions for Cochrane Heterogeneity Effective especially 2015l7 preventing unintended Systematic Only 4 in LMICs in combination pregnancies among Review (53 adolescents RCTs)
A Cochrane Systematic Review (CSR) was published in 2016 on “brief interventional strategies for improving contraceptive use in young people”. This CSR concludes: “At one year, adolescents with developmental counselling were more likely to use contraception effectively than those with
4 Lopez LM, Grey TW, Tolley EE, Chen M. Brief educational strategies for improving contraception use in young people. Cochrane Database Syst Rev. 2016 Mar 30;3:CD012025 5 Dalaba MA, Stone AE, Krumholz AR, Oduro AR, Phillips JF, Adongo PB. A qualitative analysis of the effect of a community- based primary health care programme on reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana. BMC Health Serv Res. 2016 Mar 5;16(1):80 6 Sarkar A, Chandra-Mouli V, Jain K, Behera J, Mishra SK, Mehra S. Community based reproductive health interventions for young married couples in resource-constrained settings: a systematic review. BMC Public Health. 2015 Oct 9;15:1037 7 Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. Interventions for preventing unintended pregnancies among adolescents. Cochrane Database Syst Rev. 2016 Feb 3;2:CD005215
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 2 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone standard counselling (OR 48.38, 95% CI 5.96 to 392.63). At one year, the intervention group was more likely than the standard-care group to report using an effective contraceptive and having a partner who used oral contraceptives (OCs), both at last intercourse (reported adjusted OR 1.51 and 1.66, respectively). Nearly all interventions provided multiple sessions or contacts.
In addition, UNFPA has commissioned a systematic review of the effect of demand generation interventions on uptake and use of modern contraceptives in LMIC, with Belaid as principal investigator8.
This search of the literature confirms the rationale of the DFID supported UNFPA interventions and in particular the potential for the volunteer peer educators (VPEs).
Because the evidence above was high level, the next search was restricted to “Family Planning” AND “lancet OR NEJM OR BMJ”. This did not identify any new review or guideline and the topic was not further explored.
Papers on the removal of financial barriers for Family Planning will be referred to in the discussion section.
1.2.3 Methodology of RH Surveys
1.2.3.1 Indicator – Unmet need The search strategy used was: {“contracept*” AND “unmet need}. This strategy retrieved 104 publications, of which 4 discussed definition aspects and reported on LMIC. It is of interest that in peer reviewed journals, there were varying definitions. Some are broader and others more restrictive. An example of this is exclusion of ambivalent women in the definition used by Pasha et al9 “Women with an unmet need for Family Planning were defined as those […] presumed to be fecund, and not wanting any more children at all or wanting to delay the birth of their next child; but not using any method of contraception. Women with ambivalent fertility intentions were excluded from the definition of unmet need; giving a conservative definition of unmet need.”
In summary it is important to keep in mind that confirming the observations of the previous search, there is no consensus on the definition of “unmet need”.
1.2.3.2 Using electronic devices for surveys in LMICs There is by now good validation of electronic devices and no update was done10.
1.2.4 Effect of the EVD outbreak on health services in Sierra Leone The search strategy used was: {“Sierra Leone” AND “Ebola” AND “services”}. The search retrieved 48 publications of which many were relevant showing that despite international support, the pressure on the services led to deterioration of other outcomes such as malaria, tuberculosis or obstetrical outcomes11.
8 Belaid L, Dumont A, Chaillet N, De Brouwere V, Zertal A, Hounton S, Ridde V. Protocol for a systematic review on the effect of demand generation interventions on uptake and use of modern contraceptives in LMIC. Syst Rev. 2015 Sep 28;4:124. 9 Pasha O, Goudar SS, Patel A, Garces A, Esamai F, Chomba E, Moore JL, Kodkany BS, Saleem S, Derman RJ, Liechty EA, Hibberd PL, Hambidge K, Krebs NF, Carlo WA, McClure EM, Koso-Thomas M, Goldenberg RL. Postpartum contraceptive use and unmet need for Family Planning in five low-income countries. Reprod Health. 2015;12 Suppl 2:S11 10 The purpose of the literature review is to update on relevant new validation, knowledge or understanding of the issues addressed by the survey. 11 Brolin Ribacke KJ, van Duinen AJ, Nordenstedt H, Höijer J, Molnes R, Froseth TW, Koroma AP, Darj E, Bolkan HA, Ekström A. The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone. PLoS One. 2016 Feb 24;11(2)
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1.3 Maternal and Newborn Health in Sierra Leone
Sierra Leone has growing but limited capacity in health and social sectors. It is committed to improving health services through the 2010 Free Health Care Initiative (FHCI), the 2011-2015 National Health Sector Strategy (NHSS) and the Health Sector Recovery Plan 2015 -2020 (prioritising the delivery of a Basic Package of Essential Services). Government run public services account for approximately 80% of health service utilization12. Progress has been made in improving health indicators; however the health systems remained weak. Sierra Leone remains among the countries with the lowest human development index. In 2015, its human development index of 0.413 placed Sierra Leone in the 181th position out of 188 countries. In 2014, the estimated population of Sierra Leone was 6.3 million, up from 5.5 million in 2008. An estimated 68% of the population lives in rural areas. The country has a young population, 46% under the age of 15 and 29% between 10-24 years of age. Women make up 52% of the population. Gender inequality is prevalent in the country. Women and girls in Sierra Leone suffer from discrimination and are subject to various forms of gender-based violence. Women are often relegated to roles that negatively affect their reproductive health and rights. The prevalence of female genital cutting is 89.6% (2013 SLDHS)13. Access to maternal health services is increasing. Maternal mortality ratios (MMR) remain high. Adolescent childbearing contributes to 40% of maternal deaths. Unsafe abortions account for 13% of all maternal deaths. There is a decreasing trend in neonatal, infant and under-five mortality. Table 4. Sierra Leone - Maternal health indicators Maternal health indicators DHS 2008 DHS 2013 Maternal Mortality Ratio 857 / 100.000 1.165 / 100.000 live births live births* Median age at first birth 19.3 years 19.4 years Skilled birth attendance 42.4% 59.7% Facility birth Overall 24.6% 54.4% Urban 39.5% 68.1% Rural 19.0% 49.7% Attended at least one ANC visit 86.9% 97.1% Attended four or more ANC visits 56.1% 76.0% Postnatal care within two days 58.0% 72.7% after birth Source: 2008 SLDHS. 2013 SLDHS * The difference in the MMR between the two surveys is 308 deaths per 100.000 live births. The difference in the MMR is not significant. with a Z-score of 1.911 and a p-value of 0.056
12 Ministry of Health and Sanitation Sierra Leone, 2015. Health Sector Recovery Plan 2015 -2020. 13 Statistics Sierra Leone (SSL) and ICF International. 2014. Sierra Leone Demographic and Health Survey 2013. Freetown, Sierra Leone and Rockville, Maryland, USA: SSL and ICF International
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Figure 1. Early childhood mortality rates in Sierra Leone 1999 - 2013
227 194 156 152 1999-2003 127 92 2004-2008 48 46 39 2009-2013
Under five mortality Infant mortality Neonatal mortality
Source: 2013 SLDHS
1.4 Fertility and Family Planning in Sierra Leone
Fertility in Sierra Leone has been declining but still remains high, especially among the most disadvantaged population. Total Fertility Rate fell slightly from 6 births per woman in 1990 to 4.9 in 2013. Total Fertility Rates among women in the lowest socio-economic quintile are twice those in highest quintile. Differences also exist between women in rural areas at 5.7 births per woman compared to 3.5 for those in urban areas. It varies also by level of education with women with no education having 5.6 births compared to 3.0 births among women with secondary education and above (2013 SLDHS).
Early marriage is widely practised and often encouraged in Sierra Leonean societies for various social, cultural and economic reasons, and is also associated with girls not attending school. The adolescent fertility rate is high which has implications for both the women’s and children´s health but also for their further education and employment. One in every ten women age 25-49 has given birth by age 15, and 56% became mothers by age 20 (2013 SLDHS). Early child bearing is also high among the most disadvantaged women. While 50% of the poorest 20-24 years old women had a child before age 18, only 18% of their richer counterparts did (MICS 2010).
Knowledge and use of contraceptive methods has increased since the 2008 SLDHS. In the 2013 SLDHS 95% of all women and 96% of all men responded that they know at least one method of contraception compared with 74% and 83% respectively in the 2008 SLDHS.
Table 5. Fertility and Family Planning indicators
Fertility and Family Planning indicators 2008 SLDHS 2013 SLDHS Total Fertility Rate (TFR) Overall 5.1 4.9 Urban 3.8 3.5 Rural 5.8 5.7 Age-specific Fertility Rate 15-19 146 / 1000 125/ 1000 (ASFR) 20-24 222/1000 215/ 1000 Current use modern Family Planning methods by age 15-49 6.7% 15.6% (among married women) 15-19 5.7% 7.8% 20-24 14.1% 13.6% Current use modern Family Planning methods by age 15-49 44.8% 56.3% (among sexually active unmarried women) 15-19 31.9% 53.9% 20-24 55.0% 63.6% Unmet need for Family Planning 27.6% 25.0% Source: 2008 SLDHS. 2013 SLDHS
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Early and high-risk sexual activities (including transactional sex) among young people expose them to a greater risk of morbidity and mortality, such as unintended pregnancies and unsafe abortions (abortion is illegal in Sierra Leone). Young people in Sierra Leone are sexually active at an early age. Young females start having sex and marry earlier than their male counterparts. By age 15, 19.3% of females had had their first sexual intercourse as compared to 10.4% of male counterparts, (2013 SLDHS). Young people are also among those less likely to use condoms; thereby increasing the risk for unintended pregnancies, sexually transmitted infections and HIV. Young females constitute more than half of the HIV infected among those aged 15-24. The provision of long-term contraceptives services is limited in the country, though gradually increasing.
1.5 The Ebola Virus Disease outbreak and its impact on Maternal, Newborn and Reproductive Health Services
The 2014 EVD outbreak revealed some of the weaknesses of the Sierra Leone health system, including limited human resources as well as health infrastructure, lack of prevention control measures plus other constraints in basic services necessary for the implementation of a proper outbreak response and control measures. As of March 27th 2016 a total of 14.124 cases and 3.956 deaths of EVD have been reported14. The EVD outbreak also had an economic impact reflected in declining of economic growth from 16.7% in 2012 to an estimated 4% for 2014, with The World Bank forecasting a 2% contraction for 2015. The Bank has also estimated the fiscal effects of EVD at around US$150 million15.
During the EVD outbreak there was a decline in the utilisation of Maternal, Newborn and Reproductive Health services. A UNICEF survey conducted in October 2014 among 1.185 Peripheral Health Units (PHU) in Sierra Leone, reported that 4% were closed at the time of assessment, with a similar number reporting temporary closure since the start of the outbreak16. It also reported a 23% drop in institutional deliveries; a 27% decline in the number of women coming to the PHU for their fourth antenatal care visit; 39% drop in children treated for malaria; 21% drop in children receiving basic immunization (penta3) and a 23% decline in the number of visits for prevention of mother to child transmission of HIV (PMTCT). Only one in three facilities (33%) reported to have a standard delivery bed available, 81% of the PHUs reported having delivery kits. Only 29% of PHUs had both a standard delivery bed available and delivery kits.
Reasons for the decline in utilization of health services include the absence of trusted health staff; loss of confidence by communities in the health system; safety-related reasons; stock-outs of medicines (e.g. antiretroviral).
1.6 Update on the IRMNH Programme
The UKAID is providing up to £25 million (including £5 Million to UNFPA) over four years (2012/13 to 2015/16) to support the Improving Reproductive, Maternal and Neonatal Health programme. The expected impact of the programme is “reduced maternal and newborn mortality in line with national MDG 4 and 5 targets”. The expected outcome is “Increased utilisation of quality Family Planning, Reproductive Maternal and Newborn Health services with focus on young people in Sierra Leone” and the expected outputs are:
14 https//:apps.who.int/ebola/ebola-situation-reports consulted on April 18, 2016 15 Davis, Peter. July 2015. Ebola in Sierra Leone: Economic Impact & Recovery. UK Aid, Adam Smith International, Sierra Leone Opportunities for Business Action (SOBA). 16 UNICEF. 2014. Sierra Leone Health Facility Survey. Assessing the impact of EVD outbreak on health systems in Sierra Leone.
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Output 1 Increased knowledge of integrated Reproductive, Maternal and Neonatal Health (RMNH) services in women and young people in Sierra Leone Output 2 Increased availability and uptake of modern Family Planning commodities and Sexually Transmitted Infections ( STIs) services Output 3 Increased uptake of ante-natal care (ANC), including malaria prevention, by pregnant women, with a specific focus on young people Output 4 Increased uptake of facility-based births attended by a skilled birth attendant (SBA) Output 5 Increased uptake of post-natal care (PNC) services by women
UNFPA is engaged to address nationwide demand creation; enhance community mobilisation; support outreach to young people and mass media communication for Sexual and Reproductive Health and the prevention of malaria in pregnancy and newborn; and provide training and supplies to expand and improve the quality of Family Planning and STI services in the public sector. UNFPA is primarily responsible to support Output 1 and Output 2. The main activities supported are:
Output 1 Production and nationwide broadcast of a Radio Drama “Saliwansai” covering issues of SRH/FP/STIs/ malaria. Placement of Volunteer Peer Educators (VPE) to provide SRH and Life skills lessons to young people in 60 communities throughout the country; Support to Community Wellness Advocacy Groups (CAGs) to provide information on IRMNH. counselling and referrals to health facilities Development of Information Education Communication (IEC) and Behaviour Change Communication (BCC) materials on FP/STIs. Output 2 Provision of pre-service and in-service training for health workers on FP/STIs (training of health staff on long term Family Planning methods and training of staff on adolescent and youth-friendly services) Upgrade of PHUs to provide Adolescent and Youth-Friendly Services Technical assistance to the MoHS on FP/STIs.
For implementation of these activities UNFPA collaborates closely with the Ministry of Health and Sanitation and the Ministry of Social Welfare Gender and Children Affairs. Additionally, it has sub- contracted the services of the Population Media Centre to produce and air the radio drama “Saliwansai” and Restless Development for the placement of VPEs.
There have been changes in the implementation of UNFPA supported interventions since Survey 1 was conducted, which might have influenced programme performance during the monitoring period:
The broadcasting of the Radio Drama Saliwansai came to an end in April 2014 after airing all two hundred and eight (208) episodes in two years as targeted under project period. The Programme adopted different strategies to continue implementation under the EVD outbreak, in spite of challenges such as having quarantined districts with restricted movement, high chances of infection, refusal from communities to carry out sensitization activities17:
17 UNFPA. 2014. Improving reproductive, maternal and newborn health, Progress Report for January – December 2014.
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o Regular programme activities almost stopped at the beginning of the outbreak. In discussion with DFID funds were reprogrammed to provide additional assistance to the fight against Ebola; o CAGs activities were suspended for some period in 2014 and resumed in the fourth quarter after redesigning their roles to raise awareness among the communities on Ebola infection prevention and control, hygiene practice and communicating messages on safe health facilities to utilize Family Planning services during the outbreak; o The CAGs received hygiene training and information, education and communication material (IEC), materials on FP sensitization and safe service utilization; o The CAGs were provided condoms to distribute in their communities to promote and raise awareness on Family Planning; o The CAGs record keeping and reporting system was introduced and implemented in Bonthe, Pujehun, Kono and Kailahun districts; o Due to restrictions in movement due to the EVD outbreak and the closure of schools the VPEs were selected within communities and the students reached in their communities for sexual and reproductive health sensitisation/lessons. New topics were added to their health education/promotion activities to include topics related lifesaving skills to mitigate the impact of EVD; o Family Planning commodities were fully integrated into the free health care distribution system. At the same time UNFPA also strengthened its partnership with Central Medical Store and the National Pharmaceutical and Procurement Unit and continued support to strengthen the supply chain management systems; and o The long acting FP methods were not included in the distribution of the essential drugs initially but have now been included to eliminate stock outs at the PHU levels. 2 OBJECTIVES AND METHODOLOGY OF SURVEY 2
2.1 Objectives
The overall objectives of the Survey 2 are to conduct a first measurement after the Survey 1 (baseline) and to provide an update on programme performance in relation to the interventions UNFPA is responsible for.
The specific objectives are as follows:
To monitor the effectiveness of the demand side interventions implemented by the IRMNH programme, particularly the placement of VPEs, the establishment of CAGs. To monitor availability and uptake of modern Family Planning services among males and females 10 -24 years of age. To monitor quality of care for the provision of Family Planning services at public health facilities. 2.2 Indicators to be monitored
In agreement with UNFPA, all the indicators agreed with UNFPA in May 2014 and measured by the baseline survey were also measured by Survey 2, except those related to the Saliwansai radio programme18.
18 Broadcasting of the Saliwansai radio programme was stopped in April 2014. Therefore this component was not included in this survey.
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Table 6. Indicators to be monitored by Survey 2 IRMNH Programme Source Indicators to be monitored Outcome MT Adolescent fertility rate (10-24) (births or pregnancies/1000 girls/women 10-24) Primary LF Adolescent fertility rate (15-19) (births or pregnancies/1000 girls/women 15-19) outcome Contraceptive prevalence rate (% girls/women (10-24) who are currently using a LF modern contraceptive method) Secondary MT Unmet need for Family Planning among the 10-24 years old girls/women Outcome TOR Proportion of pregnant adolescents 10-19 Output 1: Demand creation indicators. Increased knowledge % of young people (10-24) who used condoms the last time they had a sexual MT Volunteer peer intercourse (primary outcome 2) educator (VPE) % of Family Planning facility users who mention VPE interaction influencing them TOR to attend a health facility MT % of sampled facilities keeping records of CAGs referrals MT % of surveyed facility users referred by CAGs in the past year % of adolescent girls (under 19 yrs) who visited a health facility who report that LF Community they were referred by a CAG in the past year Wellness % of surveyed facility users who mention interaction with a CAG influencing MT Advocacy them to attend a health facility Groups % of young people (10-24) who have had interaction with CAGs in the past year. TOR by age and area of UNFPA intervention Develop Percentage of girls/women who have heard of more than 1 method of modern TOR IEC/BCC Family Planning, by age and disaggregated by the number of method materials on Source of information for SRH among young people (10-24) FP/STI TOR Output 2: Service delivery. Increased availability and uptake of modern FP methods % of new young acceptors (10-24) of contraceptives disaggregated by age (10- LF 14,15-19,20-24) and method % of surveyed government PHUs and hospitals without stock-outs of LF contraceptives in the last six months Delivery of FP % of (visited) government PHUs and hospitals without stock-outs of MT services contraceptives in the last three months
% of (visited) SDP with long acting Family Planning methods available (IUD and LF implants)
% of young people (10-24) considering that health services are not youth Adolescents & MT friendly Youth-Friendly Services LF Number of PHUs upgraded to provide "youth friendly services Percentage of Adolescents and Youth Friendly (AYF) Service Delivery Points LF (SDPs) meeting all 3 criteria. Percentage of Family Planning users who were informed about side effects or MT problems of methods used. % of adolescents (10-19) in Restless Development intervention areas who reported use of condom last time they had sexual intercourse. LF In survey 2, this indicator was changed to percentage of adolescents (10-19) who have met a VPE who reported using a condom the last time they had a sexual intercourse (including all young, whether they had sex or not). TOR % of providers who demonstrate good counselling skill Quality of Care TOR Percentage of providers who follow infection prevention procedure
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Source Indicators to be monitored % of women 15-49 who received Family Planning services from a SDP and were LF informed about side effects or problems of the method use TOR % of clients who are satisfied (perception) by services received Training of % or number of (visited) facilities which have at least one member of staff TOR providers trained in "youth-friendly services” LF: log-frame indicators; TOR: indicators suggested in the Terms of Reference; MT: indicators agreed between UNFPA Sierra Leone and monitoring team
2.3 Survey components
The same methodology applied in survey 1 was applied in survey 2 to monitor relevant indicators in three areas: i) reason for behaviour change, ii) quality of care and iii) access to services for adolescents and young people by means of conducting a household survey, a health facility survey and focus group discussions. However, for the household survey minor adaptations were made to update for the presence or not of VPEs in the selected clusters. The following sections present a brief description of the survey methodology.
2.3.1 Household survey The household survey focussed primarily on the effectiveness of demand side interventions for young people (10-24). It collected data on the need for and use of Family Planning and reproductive health services, as well as information on two of main UNFPA interventions at the community level (i.e. VPEs and CAGs)19. It was a cross-sectional study to identify improvements of indicators for the whole country, but also to provide detailed information on the UNFPA interventions. The sampling design includes stratification followed by four-stage cluster sampling. We have chosen to stratify the regions where the survey was carried out in four strata in order to ensure a good representation of people who would have been in contact with UNFPA interventions:
i) UNFPA Enhanced CAGs20 & VPEs (maximum intervention); ii) Standard CAGs & VPEs; iii) UNFPA enhanced CAGs & no VPEs; and iv) Standard CAGs & no VPEs.
This was an attempt to identify the impact of the interventions, however the research team is aware that there may be other interventions occurring, e.g. by an NGO, and which have not been identified. Therefore, none of the strata is a “true control” but in theory there may be a gradient of strength of intervention, to be explored both cross-sectional and for the time trend analysis. The Primary Sampling Units (PSU) were the chiefdoms which were selected randomly in the four strata. The unit of analysis is the household and the individual. The 149 chiefdoms21 in the country were allocated to the four types of intervention areas and we randomly selected four chiefdoms in each of the two strata with VPEs, and two chiefdoms in each of the strata without VPEs for a total of 12 chiefdoms. Then, four clusters were randomly selected in each chiefdom for a total of 48 clusters.
19 Survey 1 (baseline) included information on the Saliwansai radio programme. This programme has not been on the air since mid-2014, therefore no information was collected in survey 2 in relation to this intervention. 20 In this document, the abbreviation CAG+ or super CAG stands for the Community Wellness Advocacy Groups receiving direct support from UNFPA. Those are located in 4 districts: Kono, Kailahun, Bonthe & Pujehun. In the other districts of the country, there are CAGs not directly supported by UNFPA, which we label CAG- or normal CAG. 21 As in survey 1 the Western Areas was not included in this sample. However, UNFPA is currently conducting interventions in this area.
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The VPEs are placed in a limited number of communities in the country. The stratification on VPEs and no VPEs strata aimed at ensuring that we will capture young people that have met a VPE. Otherwise, we had a risk to never interview young people who had met a VPE as their coverage is not broad.
This survey covers the implementation period, after survey 1. For survey 2 we have updated the location of VPEs to cater for changes in their location under this period (June 2014 – December 2015). VPE areas are communities under the catchment area of a VPE during this period. The same districts as in survey 1 were visited. Due to updating the location of VPEs, the classification of VPEs and Non VPE areas has changed in relation to survey 1. This resulted in the following changes in survey 2:
The same chiefdoms were also visited, except one. In Moyamba District, the Kongbora chiefdom (Non VPE area) was replaced by Lower Banta (VPE+ area). The same number of VPE+ and Non VPEs clusters as in Survey 1 where kept. However, due to changes in the placement of VPEs, eight clusters have changed their status: o the four clusters in Nongowa chiefdom are classified as Non VPE clusters (no exposure to VPEs in the last 12 months, they were VPE+ clusters in Survey 1); and o applying the same random selection method as in survey 1, the four new cluster corresponding to Lower Banta chiefdom were selected. These clusters are classified as VPE+ clusters.
Table 7. Selected chiefdoms, survey 2 IRMNH
Standard Standard Enhanced Enhanced Province District Chiefdom CAGs & CAGs no CAGs & CAGs no VPEs VPEs VPEs VPEs Kenema Nongowa Gbane Eastern Mafindor Kono Nimikoro Tankoro Magbema Kambia Tonko Limba Northern Kasunko Koinadugu Sengbe Kpanda Kemo Bonthe Southern Sogbeni Moyamba Lower Banta Number of chiefdoms per intervention 4 2 4 2 area
As in survey 1, in each chiefdom, four clusters of 25 households were selected using PPS (Probability Proportional to Size), the most practical and widely used method for cross-sectional studies. This was done using the enumeration areas (EA) and their population (2004 Sierra Leone Population and Housing Census). The same sample size applied in survey 1 was applied, resulting in aiming to interview 2400 young people 10-24 years of age. Similarly, households in the cluster were selected using a random method derived from the Epi Method (random walk method). In each selected household, a list of members was established, identifying all members, eligible or not. By using a Kish
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2.3.2 Health Facility Survey The health facility survey assesses the quality of care at selected PHUs and hospitals. As requested by the ToR. the tools developed by MEASURE Evaluation for Quick Investigation of Quality (QIQ) in Family Planning Programmes were adapted to collect relevant indicators. Other questions to measure agreed indicators were added. As suggested by the QIQ methodology, information is collected in each selected facility through: observation of provision of Family Planning services, exit surveys of clients seeking FP services, and a health facility audit/Manager interview.
As agreed previously, the same 110 health facilities located in 8 districts and 62 chiefdoms sampled for survey 1 were planned to be included in survey 2. While conducting the survey one of these facilities was not operating23 resulting in a total of 10924 health facilities visited. The list of health facilities selected is included in Annex 1. In each health facility the survey team stayed a defined period of time (4 to 8 hours) in order to be able to observe at least two Family Planning client- provider consultations, to conduct the corresponding client exit interviews and the facility audit / interview of the health facility manager.
Table 8. Number of health facilities surveyed by type of health facility
Type of Surveyed facility (N=109) n %
Hospitals 9 8 CHC 45 41 CHP 36 33 MCHP 19 18 CHC: Community Health Center; CHP: Community Health Post; MCHP: Maternal and Child Health Post
2.3.3 Focus Group Discussions The focus group discussions (FGD) explored barriers to access to reproductive health services by young people 10-24 years of age. In survey 1, three districts, one from each of the three survey provinces, were purposively selected for focus group discussions. In each district two communities were selected: the district capital as a non-VPE location and another community that was randomly selected from a list of VPE sites in the district. The same locations as in survey 1 were visited for conducting the FGD.
In each location, participants were purposively selected based on age and gender. Whenever available, the team selected pregnant teenagers and lactating mothers for inclusion in the discussions. The participants in the focus group discussion were different from those that participated in the FGD conducted for survey 1. The following categories of participants were selected for inclusion in the FGDs: 10-14 years old females, 10-14 years old males, 15-19 years old
22 More explanation on the Kish grid methodology is contained in the Household Survey interviewer´s manual 23 This facility was a CHP.
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2.4 Survey questionnaires
Survey 2 used basically the same questionnaires as in survey 1 with minor adjustments. The questionnaires were revised, i) to rephrase some questions as a learning from survey 1 ii) to remove questions related to Saliwansai radio programme and iii) in response to UNFPA suggestions to add new questions related to access and utilisation of services during the EVD outbreak, observance of infection prevention procedures in health facilities, payment for Family Planning services. The revised questionnaires were discussed with and approved by UNFPA. The survey interviewer manuals used for the training of interviewers/enumerators and supervisors were also reviewed to reflect these changes.
As in survey 1, the household survey included two sets of questionnaires: 1) a household questionnaire to collect information on the household members (i.e. usual residents of the household, the household, and the dwelling) to be administered to the head of the household and 2) a separate individual questionnaire to be administered in each household to up to two members a young boy or girl between 10-24 years of age.
Similarly, as in survey 1, the three data collections instruments developed for the health facility survey were also applied in survey 2: i) the facility audit and manager survey questionnaire, ii) the observation of client provider interaction and iii) the client exit interview questionnaire.
The guide for topics to be discussed in the focus groups was also reviewed to incorporate the issues suggested by UNFPA in December 2015 (at the time of the presentation of the survey 1 report) namely to include i) money exchange for FP, ii) misconceptions about condoms, iii) desire for children and iv) premarital sex.
2.5 Data collection
2.5.1 Training of data enumerators, interviewers and supervisors One training workshop for each type of survey was conducted during the period 18 -27 January, 2016. The training was facilitated by team members from hera. FOCUS 1000 and ULB/ESP. The selection of enumerators, interviewers, supervisors and coordinators was done by FOCUS 1000, primarily from their pool of people working with them in previous surveys (including survey 1) and with experience in data collection using digital media. For new personnel the selection was done based on their experience and performance during the training.
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For the household survey, 14 people were trained; all of them except 1 were used to conduct data collection on a tablet. FOCUS 1000 had already worked with some of the enumerators and 3 of them were designated to be supervisors. One extra enumerator stayed in Freetown, available to replace any other colleague in case of need. During the 5 days of training the enumerators learn to work with the tablet and a paper questionnaire as well as software problem that may happens during the data collection.
For the health facility survey, 12 nurses were trained (8 interviewers, 4 supervisors). During the training they learnt to work both with the paper forms as well as with the digital forms. They were not familiar with the use of tablets for data collection; therefore, their training took longer than in the survey 1.
Five people (four facilitators and one supervisor) undertook the training to conduct the focus group discussions.
Table 10. Number of enumerators, interviewers and supervisors trained Survey Trainees Duration Male Female Total Category Household 9 5 14 10 enumerators, 3 supervisors, 1 regional 5 ½ days survey coordinator Health facility 1 11 12 8 interviewers, 4 supervisors 8 days survey Focus group 3 2 5 4 facilitators, 1 supervisor 4 days discussions
2.5.2 Data collection The data collection took place in the period 25th January to 28th February 2016. The field work was coordinated by FOCUS 1000. In survey 1 we introduced data collection in real time using Magpi. Since survey 1, FOCUS 1000 accumulated a great deal of experience in digital data collection. Building up on this experience, we introduced for survey 2 data collection in real time, using digital tablets. For the household survey questionnaire, the individual survey questionnaire, the health facility audit and the client exit interview the data was collected only digitally. Due to the particularities of the observation of client-provider interaction questionnaire, the data was collected first on paper forms and transcribed to the tablet before departing from the health facility.
All survey questionnaires were developed into digital format using the Open Development Kit (ODK) software. hera and FOCUS 1000 were responsible for developing and testing of the forms into the ODK software. Mohammed Jalloh from FOCUS was responsible for developing the digital data collection forms. Jan Franck from hera contributed and supervised the development of digital data collection forms, supervised data quality during data collection process and contributed to data cleaning.
The data collection for the household survey (HHS) was collected by 3 teams comprising in total of 9 enumerators, 3 supervisors, 1 regional coordinator and 1 overall coordinator. The respondent’s informed consent for participation in the survey was obtained before the interview began. The questionnaires were administered by the trained interviewers/enumerators. Where there was one male and one female of eligible age in the household, both of them were selected for the interview. Where there were more than one eligible respondents of either sex, a Kish grid was used to randomly select the interviewees. In each team there was at least one girl, to facilitate the interview with the young girls’ in each household.
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The data collection for the health facility survey was conducted by 4 teams comprising in total of 8 interviewers, 4 supervisors, 1 technical supervisor (to assist on issues related to software) and 1 overall coordinator. For both the observation of the client-provider interaction and the client exit interview, the provider or client´s informed consent for participation in the survey was obtained before the observation or interview began.
For both, the household survey as well as the health facility survey, the overall coordinators were the same as those for survey 1. They were also facilitators for the training. This contributed to continuity, sharing of experiences and taking into considerations lessons learnt during survey 1.
The FGD were conducted by two teams (each made of one facilitator and one note taker). A female/male data collection team was responsible for facilitating the FGDs among female/male participants in order to ensure that gender-sensitive issues would be openly discussed. For participants aged 10-14, informed consent was obtained from their parents or guardians, while for those aged 15 and over, informed consent was directly obtained from them. A programme manager from FOCUS 1000 supervised the qualitative data collection. All discussions were held in Krio.
2.5.3 Data management in the field The supervisors were responsible for reviewing the completed questionnaires and uploading them on a daily basis or when there was access to internet. A tracking form was also provided to the enumerators / interviewers to document the number of questionnaires completed in a given day.
2.5.4 Data analysis
The data bases for the household survey and for the health facility survey were analysed at ULB/ESP by separate teams (Michèle Dramaix. Lilas Weber, Aline Labat and Dalia Fele for the household and Wei-Hong Zhang for the health facility). Marta Medina from hera contributed to the health facility analysis and interpreted the results.
Household survey
For the household survey, the sample is described using usual statistics, mainly proportions. In the results, summary statistics for the sample are presented as well as estimates for the population. As in survey 1, population estimates and 95% confidence intervals (95% CI) were obtained using complex sample analysis techniques, taking into account the design and the sampling weights. The design is a stratified four-stages (chiefdom, enumeration area, household, individual) cluster sampling. The four strata were created for the 1st survey in terms of the UNFPA interventions: CAG+ & VPE-, CAG+ & VPE+, CAG- & VPE+, and CAG- & VPE-. The sampling weights were computed by multiplying the selection probabilities corresponding to each stage of the sampling and then taking the inverse of the resulting probabilities. The weighting allows to take into account the overrepresentation of the VPE+ areas. In addition to the individual databases of survey 1 and of survey 2, a third, “common” database combining the two surveys was developed for comparisons. Because of the design components, there may exist marginal differences in estimated proportions and confidence intervals (CI) between the combined and each individual database. As age distribution of interviewees differed slightly between survey 1 and survey 2 age adjusted estimated were obtained to compare the results from the surveys (see §3.1.2.1).
The analyses, for the household survey (data from both the head of household and individual questionnaires) was performed with STATA v12.1 (http://www.stata.com).
For the health facility analysis, the descriptive statistics used were counts (percentages) for categorical variables, mean (standard deviation [SD]) for normally distributed continuous variables,
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After checking out for incorrect values and inconsistency between observation and exit interview dataset, a merged database has been developed that included 214 matched observation and exited subjects in survey 2 (n=219 in survey 1). Further, in order to evaluate the outcomes between two periods of 2014 and 2016, a merged data sets including the subjects from two surveys has been set up including total of 433 subjects (=219 in survey 1 +214 in survey 2). Differences in outcome between the two surveys were compared by using the chi-square test.
A merged dataset for the facility audit including the two time periods has been also elaborated for the comparison. As the audit surveys were conducted in the same facility (matched pairs of subjects), McNemar's test was used to compare the proportions.
The p-values reported were two-tailed and an alpha level of 0.05 was used to assess statistical significance. Data analysed has been performed by Stata v14.0 software (Stata Corporation. College Station. Texas. USA) and IMB SPSS statistic 21.
For the focus group discussions, the data base was analysed at FOCUS 1000 by Frank Bio and James Conteh. The collected qualitative data from the discussions were thematically analysed to ensure inter-rater reliability. The first part of the analysis involved a full-read of the notes and/or transcripts by the analyst. The analysts consulted the respective data collectors to get clarifications as well as other relevant contextual information to help in interpreting the findings. Mohammad B. Jalloh, the lead researcher from FOCUS 1000, oversaw the write up of the results and shared them with the other senior members of the team for validation.
Explanations on survey methodology and results presentation UNFPA ordered a survey that would provide data on sexual and reproductive health in young people across Sierra Leone. In addition, it also needed data regarding their interventions (VPEs, enhanced CAGs and Saliwansai for survey 1) and their efficiency.
The design was therefore carefully reflected to ensure that the results would be valid for Sierra Leone (with a rigorous random selection of surveyed sites) but that we also would include enough people who benefited from UNFPA interventions (strata with interventions and over representation of VPE+ areas).
This methodology lead to a sample of 1289 households in survey 1 (2014) and 1409 households in survey 2 (2016). Our total population (from which this sample is extracted) is all households of Sierra Leone, except those from the Western Province, which was excluded because its profile was supposed to be much different from the rest (decision taken with UNFPA in 2014).
Results can be presented in two ways: sample based proportions or population based indicators.
(1) sample based proportions are calculated based on our sample, using as denominator the number of subjects in the sample who gave an answer for the considered variable.
Ex: for utilization of condom at last sex Number of young who used a condom last time they had sex (91) / Number of young who already had sex (587) = 15.5%
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This means that in our sample, we know that 15.5% of young who already had sex used a condom last time.
(2) Population based indicator is an estimation of the real proportion in our population (Sierra Leone, except Western province). This indicator is presented with an estimation in % and a confidence interval (IC95%) with a lower and upper limit within which the real value must be, accepting a 5% chance of error (real proportion is not included in 5% of the IC95% computed from samples with same sizes and selected by the same method). To estimate this “real proportion”, we need to take into account the design of the study (strata and clusters), with a special procedure that is in the statistical software. That’s why the values of sample based proportions and population based indicators may be different. If high, intra-cluster correlation decreases precision and 95%CI’s are large.
Ex: for utilization of condom at last sex 17.5% IC95% (9.2; 30.6)
This means that the real proportion in our population is estimated at 17.5%, and that we are 95% confident that the real proportion is situated between 9.2% and 30.6%.
Missing values were not too high, therefore they are not presented in the tables reporting results.
2.5.5 Ethical considerations hera received ethical clearance for the survey´s proposal from The Sierra Leone Ethics and Scientific Review Committee. In all surveys the data collection started after information about the study was provided to the interviewees and the respective informed consent was obtained.
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3 FINDINGS
This chapter presents the findings from the household survey, the health facility survey and the focus group discussions. Whenever relevant, data from interviewees from the health facility survey are referred to as family planning clients.
3.1 Characteristics of the population surveyed
3.1.1 Heads of household interviews All computations are made on the interviewed sample of 1172 households.
In survey 1, the interviewers attempted to visit 1128 households. In 1110 households one member agreed to be interviewed. Among the remaining, 12 households could not be interviewed because there was no competent respondent at the time of the visit or the entire household was absent for an extended period. For survey 2, the interviewers attempted to visit 1173 households. Only one household head refused. For survey 1, the overall response rate was 98% and in survey 2, 99.9%, which shows that the interviewers were very well received, probably highlighting good communication skills. The number of households interviewed in each of the four types of intervention areas is presented in the table 11.
In 126 out of 1172 households which had accepted to participate in the survey, there was no eligible young person for the individual interview (neither boy nor girl of age 10-24). In these households no further questions about the household itself were asked, leaving 1046 with full interview.
The design of the study was in four strata, depending on the UNFPA interventions (see §2.4 sampling frame). In table 11 the households interviewed are described in terms of stratum, district, chiefdoms and numbers.
Table 11. Number of households interviews by chiefdom – survey 2
Stratum District Chiefdom Households Gbane 100 Kono Nimikoro 100 VPE+ & CAG+ Tankoro 100 Bonthe Kpanda Kemo 100 Magbema 81 Kambia VPE+ & CAG- Tonko Limba 96 Koinadugu Kasungo 98 Moyamba Lower Banta (New) 100 VPE- & CAG+ Bonthe Sogbeni 99 Kono Mafindor 99
Kenema Nongowa 99 VPE- & CAG- Koinadugu Sengbe 101 Total households 1173 (one household head refused to be interviewed) Of these, households with at least one person 1046 10-24 years
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Most households comprised of less than 10 members and nearly 40% had 5 members or less. The profile of the households are summarised in the table 12. Table 12. Household size and composition (n=1046/1172)
Household size N % Occupation of head of household n % 1 to 5 members 449 38.3 Farmer. breeder. fisherman 666 63.7 5 to 10 members 642 54.8 Worker 121 11.6 11 to 15 members 78 6.7 Trader 118 11.3 16 members or more 3 0.3 State employee 12 1.1 Professional 73 7.0 Young People Community leader 13 1.2 642 642 10-24 n % n % No job 25 2.4 0 eligible 360 34.4 269 25.7 Other 18 1.7 1 eligible 418 40.0 482 46.1 2 eligible 162 15.5 197 18.8 3 eligible 68 6.5 76 7.3 4 or more 38 3.7 22 2.1
The vast majority of household heads worked in the primary sector: agriculture or fishing. More than half owned some land. In addition to their occupation, we asked about a list of household assets and about the source of drinking water to assess the socio-economic level of the household. We used the same list of items used in the 2013 Sierra Leone Demographic Health Survey (SLDHS), however, for clarity, we regrouped some sources of water and we did not include some assets that were owned by less than 10 households (table 13)
Table 13. Household assets and sources of drinking water Survey 2 Survey 2 IRMNH IRMNH Durable Source of drinking water 2016 SLDHS 2013 2016 SLDHS 2013 household assets n=1046 Rural Urban n=1046 Rural Urban % % % % % % Improved source 50.9 47.5 89.2 Electricity 4.0 N/A N/A Piped into dwelling/yard 0.2 0.3 10.9 Radio 60.8 51.3 75.1 Public tap / standpipe 22.7 7.9 34.4 Refrigerator 0.5 0.3 19.6 Tube well / borehole 6.3 20.6 7.5 Television 2.7 2.4 37.9 Protected dug well 19.5 16.9 27.2 Mobile phone 60.8 41.1 84.7 Protected spring 2.2 1.1 1.6 Watch 23.8 N/A N/A Non-improved source 49.1 52.3 10.6 Bicycle 4.8 8 7.1 Unprotected dug well 10.3 9.9 5.5 Motorbike 4.4 8.1 3.3 Unprotected spring 24.8 17.1 1.5 Agricultural land 81.3 79.5 22.9 Tanker truck / cart with N/A: not available 0.1 0.1 0.6 tank Surface or rain water 14 25.2 3 Bottled / packaged water 0 0 0.2 Missing 0.2 0.2
About 51% of surveyed households had access to an improved source of water, which is in the same order of magnitude as the previous IRMNH survey (60%) and to the rural parts of the 2013 SLDHS (47.5%).
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Most of those who worked in agriculture owned their land but there were very few additional assets beyond mobile phones and radios. The possession of assets has not changed between survey 1 and survey 2. The household profiles are overall quite similar to those of the 2013 SLDHS indicating that this survey used an appropriate sampling strategy.
Access of surveyed households to health facilities (fig. 2) and education services (fig. 3) was also addressed. Figure 2. Time to reach closest health facility by transportation means (% of households)
79.2 83.1
by foot survey 1 (n=1097) 51.8 48.4 by foot survey 2 (n=1406) by car survey 1 (n=1084) 24.1 26.1 24.2 25.5 16.1 15 by car survey 2 (n=1046) 4.6 1.9
< 30 minutes >= 30 minutes > 60 minutes
Figure 3. Time to reach the closest school by foot (% households)
81.9 71.6 by foot survey 1 (n=1100) by foot survey 2 (n=1046) 20.1 11.1 7.0 8.3
< 30 minutes >=30 -60 minutes >=60 minutes
There was an increase in families which lived more than 30 minutes away from school (18% in survey 1 and 28% in survey 2). This has been assumed to be due to random variations rather than to any fundamental change, such as closure of vicinity facilities but needs to be confirmed by local collaborators.
Overall, above 70% of households could reach a school in less than 30 minutes by foot, but only about half were less than 30 minutes away from a health facility.
3.1.2 Individual interviews All computations are made on the interviewed sample of 1409 (1289 in survey 1). As in 2014 the aim was, if available, to interview one boy/man and one girl/woman aged 10 to 24 in each household. In most households, the interviewer did not find two eligible youths. In total, 1409 eligible individuals were identified once the head of household agreed, all young people agreed to be interviewed.
3.1.2.1 Age and Sex The age and sex distribution was slightly skewed towards girls/women (757 female/ 652 male) and towards the youngest age group, with the smallest representation for the 20-24 group. This was similar to the baseline and is assumed to be due to the fact that young people who are male, and/or in the older age groups are more likely to be out of the house at the time of interview. The higher
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In survey 2 (2016) the proportion of boys 20-24 was only 15% compared to 21% in survey 1 (2014) (fig 4). This difference is statistically significant (chi2 = 8.493 p<0.01) and has justified adjustment on age in the comparisons between survey 1 and survey 2 for the computation of confidence intervals of indicators (table 1 and §3.7).
Figure 4. Age and sex distribution of young (10-24) interviewed in both surveys (%)
Survey 1, females (n=689) Survey 1, males (n=599)
26.7 10-14 yrs 21.7 10-14 yrs 41.4 46.9 15-19 yrs 15-19 yrs 31.9 20-24 yrs 31.4 20-24 yrs
Survey 2, females (n=757) Survey 2, males (n=652) 15.34
10-14 yrs 10-14 yrs 23.78 43.06 15-19 yrs 15-19 yrs 33.16 33.28 51.38 20-24 yrs 20-24 yrs
As in survey 1, ages were not evenly distributed but there was an excess of round ages (10. 12. 15 and 20). One explication is that some interviewed persons did not precisely know their age. If the rounding is purely random, this is not a problem. However, if there is a systematic direction (either towards younger than reality or the opposite), this could introduce a bias into the analysis of some indicators that require adjustment for age. It has been assumed that there is no systematic bias.
There were 1409 young people 10 -19 years of age, of which 55.6% (757) were girls and 46.3% (652) were boys.
By design, two thirds of the clusters surveyed were located in areas considered to be exposed to VPEs (65.2% of interviewees) and one third in “non VPE” areas (34.8% of interviewees).
3.1.2.2 Education, literacy, language and religion For survey 1, it was accepted that in the older age groups (15-24) interviewees might have had difficulty in attending school, because they were of school age during the Civil war. We therefore expected that for survey 2, this problem would not be finished, but that in addition the EVD outbreak would have further worsened the prospects for education. This concern led to adding a new question: “are you at present in school, training or higher education?”. The results were encouraging as can be seen in table 14. This shows that between the age of 10 and 14, despite all the recent difficulties, over 90% of youngsters between 10 and 14 are attending schools, and girls as much as boys. In addition, the estimate in survey 1 was that among the interviewed, 73% were currently enrolled in school or studies.
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The highest level attained by those who were currently in school and out of school is also presented in the table 14.
Table 14. Percentage in education or training by age and sex Education Total Male Female level In education (n=652) (n=757) Age 10-14 15-19 20-24 10-24 10-14 15-19 20-24 10-24 10-14 15-19 20-24 10-24
In education 305 169 61 535 302 171 58 531 607 340 119 1066 Not in education 30 48 39 117 24 80 122 226 54 128 161 343 Total by age group 335 217 100 652 326 251 180 757 661 468 280 1409 % in education 91.0 77.9 61.0 82.1. 92.6 68.1 32.2 70.2 91.8 72.6 42.5 75.7 Highest level Male (n=416) Female (n=518) Total of education recoded % 10-14 15-19 20-24 10-24 % Age 10-24 % 10-24
None25 126 30.3 178 34.4 154 78 72 304 32.5 Primary school attended 246 59.1 244 47.1 380 81 29 490 52.5 Primary school completed 22 5.3 45 8.7 12 25 30 67 7.2 JSS completed and more 22 5.3 51 9.9 2 27 44 73 7.8
Total 416 100.0 518 100.0 548 211 175 934 100.0
For the educational level “primary school attended”, males were more represented than females. However, there were more females in higher education level (primary school completed or JSS completed and more). There was no difference between sex for those with highest level of education “none.”
Other characteristics explored were religion and language/ethnicity. Among the interviewees 64% were Muslim and 35% Christian (similar to SLDHS 2013 and to survey 1). The distribution of first languages spoken by the interviewed differs from the national profile where there is roughly one third Temne, one third Mende and one third “other”. This was also the case in survey 1, which was to be expected as all but one area, were similar in both surveys. It is unlikely to have an impact on the analysis. Table 15. Language spoken by respondents Survey 1 (n=1289) Survey 2 (n=1409) Mende 33% 33% Temne 16% 9% Kono 15% 18% Limba 14% 13%
25 None includes both people who have never been to school but also people who are at primary school. It is suggested for another survey to create a new category: not at school at present and never attended.
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All others 22% 24%
All those who had not reached secondary school level were asked to read a simple sentence in large characters: “the child is reading a book”. A composite indicator of literacy was then created: The secondary school graduates, the children in secondary school and those interviewees who could read the sentence completely or in part were coded as “can read”. All others were coded as “cannot read”. Some concern remains for the fact that 37% of boys and 47% of girls cannot read proficiently. Results are presented by sex in table 16. In figure 5 the age distribution of people unable to read is shown. Table 16. Ability to read Ability to read Male (n=652) Female (n=757) All (n=1409) n % N % n % Able to read 412 63.2 400 53.0 812 57.7 Cannot read at all 240 36.8 355 47.0 595 42.3 Total 652 100 755 100 1407 100
Figure 5. Percentage of young people who cannot read, by age
59% 49% 51%
26% 28% Male 21% Female
10-14 yrs… 15-19 yrs… 20-24 yrs…
The findings show that the highest rate of young people who cannot read is found in the 10-14 years old category. This result is quite similar to survey 1 (53% of male and 52% of female). A high rate of illiteracy is also found in women from 20-24, as in survey 1. In the age group 15-19, literacy rate is quite similar between male and female.
From the 2013 SLDHS, the literacy rate in the age group 15-24 is quite similar to our survey: 69% country wide, which has clear implications for policy making, dissemination and implementation of Family Planning programmes.
3.1.2.3 Health behaviour: use of mosquito nets and hand washing As in survey 1, there was a question about sleeping under a mosquito net the previous night. There were more than two thirds of positive answers (69%) which was a marked improvement compared to survey 1 where only 49% had.
Because of the EVD outbreak, two new questions on hand washing were added in this survey: “did you wash your hands in the last 4 hours?” and, if yes, “in what circumstances”. The answer was positive for 72%. The “circumstances” clustered around “after using the toilet (90.7%)”, and “before eating (87.6%)”.
It would be of interest to test these items as possible predictors of safe sex behaviour.
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3.1.3 Health facility survey We surveyed a total of 109 health facilities, approximately half of them (41%) were community health centres, 33% community health posts, 17% maternal and child health post and 8% hospitals. The great majority were located in rural areas. The detailed list of health facilities by chiefdom and type of health facility can be found in Annex 1.
Table 17. Health facilities surveyed (n= 109) n % n %
Province District East 24 22.0 Bonthe 12 11.0 North 55 50.5 Kailahun 19 17.4 South 30 27.5 Kambia 6 5.5 Type Kenema 19 17.4 Hospital 9 8.3 Koinadugu 17 15.6 Community Health Centre 45 41.3 Kono 18 16.5 Community Health Post 36 33.0 Moyamba 15 13.8 Maternal and Child Health Post 19 17.4 Pujehun 3 2.8 Location Rural 99 90.0 Urban 10 10.0
As in survey 1, most of the health facilities were not connected to a central electricity supply grid. However, in survey 2 a larger percentage of health facilities had electricity available on the day of the visit (77% in survey 2 vs. 11% in survey 1). A quarter of health facilities visited had a dedicated room for Family Planning services, up from the 10% recorded in survey 1.
All surveyed health facilities offered Family Planning services, which is in line with the guidelines of the Sierra Leone Basic Package of Services. More than two thirds of health facilities offered Family Planning services every day of the week including weekends (73% in survey 1). As in survey 1, more than 80% of CHCs and MCHPs offered Family Planning services every day, including weekends (See Annex 4). 90% of health facilities visited provided Family Planning services during the EVD outbreak.
Table 18. Infrastructure and service conditions for the provision of FP services Health Facilities n % Infrastructure Connected to central electricity supply grid (n=109) 9 8.3 No electricity available on the day of the visit (n=107) 22 22.6 Availability of an electricity generator or solar supply (n=108) 68 63 Waiting area with sheltered seating (n=109) 105 96.3 A dedicated room for Family Planning services (n=109) 27 24.8 A shared room with other services (n=109) 76 69.7 Counselling and clinical exam in the same room (n=109) 87 79.8 Different room for clinical exam (n=109) 22 20.2 Family Planning services offered (n=109) Services advertised by sign post on the street 50 45.9 Services every day including weekend 73 67.0 Services every day without weekend 23 21.1 Services only on specified days or times 13 11.9 Offering FP services during the EVD outbreak 98 89.9
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3.1.4 Family Planning clients A total of 98% of the planned number of observations and client exits interviews were conducted for a total of 214 each26. The participants included primarily females 12-45 years old (only 7 males). The median age was 24 years (25 years in survey 1) with the inter-quartile range (IQR) between 20-30 years. Half of the Family Planning clients were young people between 12-24 years of age. Approximately half of them (46%) were new clients. 22% had never given birth (26% in survey1). Among those that had given birth, 58% want more children (less than the 67% in survey 1). 85% of Family Planning clients were unable to read (76% in survey 1) and 7.6% were not in a union. Table 19. Characteristics of Family Planning clients (n=214) N % n %
Age in years (n=211) Marital status (n=211)
<14 4 1.9 Married 97 46.0 15-19 43 20.4 Living with partner 40 19.0 20-24 59 28.0 In a union / not living together 58 27.5 25-29 52 24.6 Not in a union 16 7.6 30-34 23 10.9 35-39 20 9.5 Number of given birth per women (n=214) 40-45 10 4.7 0 47 22.1 1 45 21.1
Sex (n=211) N % 2 41 19.2 Male 7 3.3 3+ 80 37.6 Female 204 96.7 Don´t know 1 Currently in education or training (n=212) Yes 72 34.1 Wants more children ( n=167) Missing: 47 No 131 65.9 Depends on God or on husband 9 5.4 Depends on God 5 3.0 No 49 29.3 Highest level of education (among those not Don’t know 7 4.2 currently in training) (n=142) None 89 62.7 Timing of next birth (n=97) Primary school attended 12 8.5 1-2 years 16 16.5 Primary school completed 8 5.6 > 2 years 69 71.1 Don´t know 12 12.4 Junior secondary 16 11.3 completed Senior secondary Family Planning use as reported by client (n=211 14 9.9 completed Vocational training New client 98 46.4 1 0.7 completed Higher education 2 1.4 Continuing client 113 53.6 Able to read a text (among those with no education or primary education) (n=109) Unable to read 93 85.3 Able to read whole sentence 3 2.8 Able to read only parts of sentence 13 11.9 *Missing: 47
26 A total of 220 observations of client- provider interaction were recorded in observational electronic database and 217 exit interviews were recorded in exit electronic database. After check out for the inconsistence and unusual values between two database, a total of 214 matched subjects were included in the analysis.
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Sleeping under a mosquito net last night was reported by 85% of Family Planning clients interviewed. Washing hands with soap or hands hygiene was a health message widely promoted during the EVD outbreak. We inquired about this practice. It appears that this is currently a common practice among the interviewees, 79% of Family Planning clients interviewed reported having washed their hands with soap or using hands hygiene within the last four hours and 10% more than four hours ago.
3.1.5 Family Planning service providers In 92% (80% in survey 1) of the Family Planning encounters observed, the service provider was a female. Most Family Planning encounters observed were provided by two cadres Maternal and Child Health Aides (46%) and State Enrolled Community Health Nurses (SECHN) (21%). The type of provider varied by the type of health facility. At the hospitals SECHN were the most frequent provider. At community health posts (CHP) and maternal and child health posts (MCHP) more than half of the Family Planning consultations were provided by Maternal and Child Health Aides. At the community health centres (CHC) Maternal and Child Health Aides provided 40% of the consultations observed and enrolled midwives 20%. Only at CHC, we observed Community Health Officers (CHO) providing Family Planning consultations. See Annex 3.
Table 20. Type of providers of Family Planning encounters observed
All Type of provider n % State Registered Nurse 1 0 SECHN 46 21.5 Registered Midwife 17 7.9 Enrolled Midwife 26 12.1 CHO 13 6.1 Community health assistant 10 4.7 Maternal and child health aide 99 46.3 Other 2 Total 214 100.0
3.1.6 Participants in focus group discussions A total of 105 young people 10 - 24 years of age (50% female. 50% male) participated in the 16 focus group discussions. The composition of the groups by age, sex, and occupation is presented in table 21 and table 22. Table 21. Number of participants in focus group discussion by age Number of FGD Number of participants Age group (n=16) (n=105) Female Male Total % Female Male Total % 10-14 yrs 3 3 6 37.5 20 19 39 37.0 15-19 yrs 3 3 6 37.5 19 20 39 37.0 20-24 yrs 2 2 4 25.0 14 13 27 26.0 Total 10-24 yrs 8 8 16 100.0 53 52 105 100.0
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Table 22. Characteristics of participants in focus group discussions by age group Female Female Female Male Male Male 10-14yrs 15-19yrs 20-24yrs 10-14yrs 15-19yrs 20-24yrs Students. Students. Students. Students. out Students. Students. pregnant pregnant girls. pregnant of school motor-bike business men. girls. lactating mothers. women. rider. farmer farmer. lactating trader lactating mothers. mothers. seamstress seamstress. farmer. trader
3.2 Adolescents and youth: sexuality and access to Family Planning services
3.2.1 Sexuality and Family Planning
3.2.1.1 Sexual activity For the individuals in the household survey, all computations are made on the interviewed sample of 1409. Regarding sexual activity only 2/1409 declined to answer, compared to 13 in survey 1. These two people have been included in the “yes” category. This decision was the same as in survey 1 and was taken due to the sensitivity of the question. Results of survey 1 and survey 2 are similar (table 23). The proportion of young people who reported sexual initiation increased with age (fig. 6).
Table 23. Sexual initiation (survey 1: n=1289; survey 2 n= 1407) Male Female Total n % n % n %
Has had sexual intercourse Survey 1 230 38.3 360 52.2 590 45.8 Has not had sexual intercourse Survey 1 370 61.6 329 47.7 699 54.2 Total survey 1 600 100 689 100 1289 100 Has had sexual intercourse Survey 2 207 31.8 382 50.3 587 41.7 Has not had sexual intercourse Survey 2 445 68.1 374 49.5 820 58.3 Total survey 2 652 100 756 100 1407 100
Figure 6. Proportion of young people who ever had a sexual relation, by age
Male 2014 (n=600); male 2016 (n=652); female 2014 (n=689); female 2016 (n=756)
There seems to have been no time trend when categorized according to age group. In fact, for girls aged 10-14 there was even a marginal increase in sex activity from 6% in survey 1 to 8% in survey 2.
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3.2.1.2 Negotiation and condom use We asked Interviewees of both sexes who had reported sexual initiation whether they could ask their partner to use a condom and whether they could ask not to have sex. Negotiation aspects, be it for condom use or not having sex have apparently not improved between the surveys (table 24); however, the number of refusals to answer between surveys has decreased from around 10% to less than 1%, which may be the simple explanation for the change.
Table 24. Negotiation of condom use / negotiation of not having sex, survey 1 and survey 2 Male Female Total
10-24 yrs 10-24 yrs 10-24 yrs % % % Thinks it is OK if girl asks boy to use a condom: yes / Can ask boy to use a condom: yes Yes, survey 1 (missing = 48) 52.3 38.5 43.4 (n=191) (n=351) (n=542) Yes, survey 2 (missing = 2) 46.8 34.0 38.5 (n=205) (n=379) (n=584) Yes, survey 1 (missing = 71) 69.6 66.5 66.1 (n=185) (n=334) (n=519) Yes, survey 2 (missing = 2) 61.2 62.6 62.1 (n=206) (n=380) (n=586)
Younger people, who probably need it most are those which feel least capable of negotiating condom use or abstinence (table 25). In the same way, young people not in union find asking not to have sex less acceptable than those in union (56% vs 68%).
Table 25. Negotiation of condom use / negotiation of not having sex , by age and sex,, survey 2 Male Female Total % % % (total n) (total n) (total n) Thinks it is OK if girl asks boy to use a condom: yes / Can ask boy to use a condom: yes 53.3 36.0 42.5 10-14 years (n=15) (n=25) (n=40) 46.4 39.8 42.1 15-19 years (n=97) (n=176) (n=273) 46.2 28.1 34.3 20-24 years (n=93) (n=178) (n=271) 46.8 34.0 38.5 10-24 years (n=205) (n=379) (n=584) Thinks it is OK if girl asks boy not to have sex: yes / Can ask boy not to have sex: yes 40.0 52.0 47.5 10-14 years (n=15) (n=25) (n=40) 62.2 67.8 65.8 15-19 years (n=98) (n=177) (n=275) 63.4 59.0 60.5 20-24 years (n=93) (n=178) (n=271) 61.2 62.6 62.1 10-24 years (n=206) (n=380) (n=586)
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Among sexually active interviewees, 15.5% reported that they had used a condom during last intercourse (27.7% of male and 8.9% of females). Among those who were not in union, the rate was 27.7% for boys and 17.7% for girls (table 26). The observation is that there has been a global increase, and that this is marked more for women not in union and young women.
When the interviewee replied to have used a condom at the previous intercourse, he was asked if he had regularly used condoms. Use was consistent in 69%, unchanged from the previous survey (table 26).
Condom use was related to education levels (as expected), but not to UNFPA areas (as it was in survey 1). In general, the number of condom users is small and it is therefore not possible to control for many variables. Therefore, interpretation of the results has to be done with sufficient caution.
Table 26. Condom use, by sex, survey 1 and survey 2 Male (10-24) % Female (10-24) % Total % Survey 1 Survey 2 Survey 1 Survey 2 Survey 1 Survey 2 Used condom at last intercourse (n=224) (n=206) (n=349) (n=381) (n=569) (n=587)
Yes 22.3 27.7 6.6 8.9 12.7 15.5 *Missing values in 2014 = males 6. females 11. Used condom and not in a union (n=128) (n=206) (n=103) (n=381) (n=231) (n=301)
Yes 29.7 27.7 12.6 17.6 22.1 22.6 Used condom each time last year among those using condom at last intercourse (n=50) (n=56) (n=26) (n=34) (n=76) (n=90)
Yes 60 69.4 46.2 67.6 66.1 68.9
As in survey 1, determinants of condom use (see also §3.7.1.5) were also analysed. All markers of education were determinant (fig 7). In survey 1, the UNFPA intervention areas were also determinant; in survey 2, they were not.
Figure 7. Condom use among boys/men and girls/ women (%)
Boys/men Girls/women
When analysing negotiation for condom use and not having sex by having met and not having met a VPE the results suggest that negotiation both for sex and use of condom is generally easier for people who have met a VPE than for those who haven’t. Sex negotiation seems to be easier than condom negotiation, especially when getting older.
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Table 27. Negotiation of condom use /negotiation of not having sex among young (10-24 yrs)who have met a VPE, survey 2
Male Female Total % % %
(total n) (total n) (total n) Thinks it is OK if girl asks boy to use a condom: yes/ Can ask boy to use a condom:yes 50.0 58.3 55.0 10-14 years (n=8) (n=12) (n=20) 57.1 51.1 53.4 15-19 years (n=56) (n=92) (n=148) 58.5 41.7 48.5 20-24 years (n=41) (n=60) (n=101)
57.1 48.2 51.7 10-24 years (n=105) (n=164) (n=269) Thinks it is OK if girl asks boy not to have sex / Can ask boy not to have sex 37.5 58.3 50.0 10-14 years (n=8) (n=12) (n=20) 62.5 78.3 72.3 15-19 years (n=56) (n=92) (n=148) 78.1 71.7 74.3 20-24 years (n=41) (n=60) (n=101) 66.7 74.4 71.4 10-24 years (n=105) (n=164) (n=269)
Table 28. Negotiation of condom use /negotiation of not having sex among young 10-24 yrs who have not met a VPE, survey 2 Male Female Total % % %
(total n) (total n) (total n) Thinks it is OK if girl asks boy to use a condom: yes / Can ask boy to use a condom:yes 57.1 15.4 30.0 10-14 years (n=7) (n=13) (n=20) 31.7 27.7 29.0 15-19 years (n=41) (n=83) (n=124) 36.5 19.8 25.0 20-24 years (n=52) (n=116) (n=168)
36.0 22.6 26.9 10-24 years (n=100) (n=212) (n=312) Thinks it is OK if girl asks boy not to have sex: yes / Can ask boy not to have sex: yes 42.9 46.2 45.0 10-14 years (n=7) (n=13) (n=20)
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61.9 57.1 58.7 15-19 years (n=42) (n=84) (n=126) 20-24 years 51.9 51.7 51.8 (n=52) (n=116) (n=158) 55.5 53.5 54.1 10-24 years (n=101) (n=213) (n=314)
The results of the analysis of negotiation for condom use and not having sex by having met and not having met a CAG, suggests that here as well, in both cases having sex negotiation seems to be easier than condom negotiation.
Table 29. Negotiation of condom use /negotiation of not having sex among young 10-24 yrs who have met a CAG, survey 2 Male Female Total % % %
(total n) (total n) (total n) Thinks it is OK if girl asks boy to use a condom: yes / OK if girl asks boy to use a condom: yes 100.0 50.0 60.0 10-14 years (n=1) (n=4) (n=5) 50.0 25.8 32.6 15-19 years (n=26) (n=66) (n=92) 35.3 21.3 23.4 20-24 years (n=17) (n=94) (n=111)
45.5 23.8 28.4 10-24 years (n=44) (n=164) (n=208) Thinks it is OK if girl asks boy not to have sex: yes / Can ask boy not to have sex Can ask boy not to have sex: yes 100.0 50.0 60.0 10-14 years (n=1) (n=4) (n=5) 69.2 62.1 64.1 15-19 years (n=26) (n=66) (n=92) 47.1 48.9 48.6 20-24 years (n=17) (n=94) (n=111)
61.4 54.3 55.8 10-24 years (n=44) (n=164) (n=208) Note: n are very small for some modalities (n male 10-14 yrs=1)
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Table 30. Negotiation of condom use /negotiation of not having sex among young 10-24 yrs who have not met a CAG, survey 2 Male Female Total % % %
(total n) (total n) (total n) Thinks it is OK if girl asks boy to use a condom: yes / OK if girl asks boy to use a condom: yes 53.9 33.3 41.2 10-14 years (n=13) (n=21) (n=34) 45.1 48.2 47.0 15-19 years (n=71) (n110) (n=181) 48.0 35.7 41.5 20-24 years (n=75) (n=84) (n=159) 10-24 years 47.2 41.9 44.1 (n=159) (n=215) (n=374) Thinks it is OK if girl asks boy not to have sex: yes / Can ask boy not to have sex Can ask boy not to have sex :yes 38.5 52.4 47.1 10-14 years (n=13) (n=21) (n=34) 59.7 71.2 66.7 15-19 years (n=72) (n=111) (n=183) 66.7 70.2 68.6 20-24 years (n=75) (n=84) (n=159) 10-24 years 61.3 69.0 65.7 (n=160) (n=149) (n=376)
As in survey 1, there is still much misgiving about condoms as can be seen in the textbox, which reports some of the reasons given by interviewees for not using a condom. The two last comments about “being raped” show that this topic possibly also needs to be addressed in addition to the condom and sex negotiation aspects by the health education and promotion interventions.
Reasons given for not using a condom (2016) • Just don't want to • Don’t know how to use it • Didn't think of it • Does not avoid sexual transmitted disease • Use it when he feel like using it • Condom is a sickness to me that why • Worried about side-effects (health concerns) • Condom is of no use to me • Don’t know how to use it • I was raped • Because I was raped
3.2.1.3 Family Planning and Sexually Transmitted Infections (STIs): knowledge and utilisation In the survey questionnaire, we asked about the use of Family Planning (modern and other methods) and about Sexually Transmitted Infections.
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Use of Family Planning was assessed through two sets of questions, the first pertaining to the last episode of intercourse, and the second to current use. In survey 2, among those interviewed, 249 reported being users of modern FP methods. For use of modern contraception on last sexual intercourse, 54.1% of boys and 42.7% of girls who were sexually active said “yes”, while in survey 1, 50.5% of boys and 34.9% of girls who were sexually active said “yes”.
The results for type of methods used were very similar to survey 1. For girls/women the three most commonly used methods remain injectables, implants and oral contraceptive pills, while males continue to report condoms, implants and injectables most frequently. Because injectables need to be repeated every three months, these data were disaggregated by distance to the health facility. The distribution was the same as in the global population, implying that once the woman uses injectable contraception, returning for a renewal is not a problem.
For current use of modern contraception, the results were analysed in terms of distance to the health facility (table 31).
Table 31. Distance to HF and use of modern methods, survey 1 and survey 2 Survey 1 Survey 2 % use of modern % use of modern Distance to HF Distance to HF method method Less than 30 min (n=136) 39.7 Less than 30 min (n=140) 28.6 30 - 60 min (n=91) 35.2 30 - 60 min (n=73) 27.4 >60 min (n=105) 24.2 >60 min (n=84) 39.3
There was a gradient, marked for distances above 60 minutes, in survey 1, not so evident in survey 2.
The choice of commodities was explored (table 32). In effect, only a limited number of methods are in use, though some respondents declared having used more than one method.
Table 32. Modern contraceptive methods used (current users)
Number of times the method was mentioned Contraceptive Male Female Total Total method (n=100) (n=149) (n=277) % Female Sterilization 0 2 2 0.7 Male Sterilization 1 0 1 0.4 IUD 0 4 4 1.4 Injectable 26 50 76 27.4 Implant 40 51 91 32.9 Pill 10 38 48 17.3 Male Condom 38 15 53 19.1 Female Condom 1 1 2 0.7 Emergency 0 0 0 0 Contraception Total 116 161 277 100
We asked female sexually active non-users why they did not use a modern Family Planning method. More than 40% of interviewees reported they did not need contraception because the woman was pregnant or trying to get pregnant. The reasons for the remaining non-users are presented in figure 8. There has not been improvement since survey 1 and concern remains that most of these reasons are amenable to action: information and individualised care in the health facility.
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Figure 8. Comparison between survey 1 and survey 2 of motives for not using modern contraceptives, (% young 10-24 years non users, not pregnant and not attempting pregnancy and not fertility related)
23 51 Opposition to use 40 42.2 23 21.3 Lack of knowledge 16.3 11 29.7 38.3 Methods related 26.1 21.6
Male survey 1 Male survey 2 Female survey 1 Female survey 2
It is of interest that once more “opposition to use” is a noticeable reason. This concurs with various recent qualitative analyses in Sub-Saharan Africa among others one by Dalaba et al27, in Ghana, reporting that interviewees expressed concerns about contraceptive side effects, prominently permanent sterility. They conclude that strategies for male outreach and community engagement need to be reinforced, especially with specific attention to the needs of men. This is in agreement with the data in the surveys, where especially in survey 2, it is the men more than the women who mention lack of knowledge and attitudinal resistance.
Interviewees were asked about STIs, both their knowledge, and their personal experience (table 28).
Table 33. Knowledge and personal experience of STIs, survey 2 Male Female Total % % % (total n) (total n) (total n) Ever heard about 47.9 57.5 53.1 Yes (denominator all) (n=639) (n=751) (n=1390) 53.9 66.5 60.5 Yes (denominator VPE exposed) (n=293) (n=322) (n=615) Yes (denominator CAG exposed) 59.5 78.5 73.4 (n=79) (n=214) (n=293) Ever experienced (denominator: those who already had sex) 9.6 4.3 6.1 Yes (n=156) (n=304) (n=460) Went to a health facility for STI (denominator: those who had STI) 93.3 92.3 92.9 Yes (n=15) (n=13) (n=28)
About half in survey 2 (two thirds in survey 1) of all interviewed individuals had heard about sexually transmitted infections. Our relatively younger population compared to survey 1 may explain this
27 Dalaba MA, Stone AE, Krumholz AR, Oduro AR, Phillips JF, Adongo PB. A qualitative analysis of the effect of a community- based primary health care programme on reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana. BMC Health Serv Res. 2016 Mar 5;16(1)
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 34 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone difference. All who were sexually active were asked whether they ever had an STI; 28 individuals answered yes, all but two of these sought care at the health facility.
3.2.1.4 Marriage. partnership. sexual activity. childbirth history as markers of need for Family Planning Determinants of demand and use of Family Planning services were explored further, in particular: union, frequency of sexual intercourse, number of children.
For “being in union”, results are similar to the previous survey with 28% (30% in survey 1) of females and 69% (60% in survey 1) of males who reported having had sex and not in a union. This needs to be kept in mind when constructing indicators for unmet Family Planning need. Considering only people in a union28 would leave out a large population of sexually active young people who also, possibly even more, need to avert an undesired pregnancy.
Another component of need for Family Planning is the frequency of sexual activity (table 34).
Table 34. Comparison of sexual activity frequency among young 10-24 years, by sex, survey 1 and survey 2 Male Female Survey 1 n=225 n=351 Survey 2 n=203 n=379 % % Last 7 days Survey 1 56.9 40.8 Survey 2 44.3 42.5 8 - 90 days and “can’t remember” Survey 1 32.9 30.5 Survey 2 44.4 25.1 More than 90 days Survey 1 10.2 28.7 Survey 2 11.3 32.4
This item allows to identify the “sexually active” young 10-24 years and will be also used for the analysis of unmet needs for FP. Those who declared having had sex in the last three months or who could not remember when they last had sex were considered sexually active. This has not changed over the two surveys, and shows that for the vast majority of these young people, once sexual activity has started it becomes frequent (table 35).
Another approach to need for Family Planning is to examine the number of women who have already had children.
28 Definition of unmet need for FP “the proportion of women of reproductive age who are married or in a union and who do not want any more children or want to wait at least two years before having a baby, and yet are not using contraception” (World Health Statistics 2012)
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Table 35. Children and sexual activity by age (female only)
Age Have one or more child Pregnant Already had sex Total
n % of total n % of total n % of total 10-14 4 1.2 0 0 26 8.0 326 15-19 71 28.3 22 8.8 177 70.5 251 20-24 133 73.9 13 7.2 178 98.9 180 10-24 208 27.5 35 4.6 381 50.3 757
The implications of these data are that 1% of girls in the age group 10 to 14 years of age have already had children and that by the age group 15-19 years, 28% already had children. This confirms again, that the definition of “unmet need” probably needs to be broadened in the context of Sierra Leone.
3.2.2 Utilisation of health services All young individuals (10-24 years) interviewed in the household survey, were included for the questions related to utilisation of health services. In survey 2, 28.5% of males and 43.9% of females used the health facility services in the past year. The difference between both sexes is in part due to the components of SRH such as pregnancy care and Family Planning, but girls/women are more likely to use the health facility also for other reasons such as malaria.
Table 36. Health facility utilisation and reasons for using it among subjects who reported use of the health facility in the past year
Males Females Total Survey 1 n=585 n=679 n=1264 Survey 2 n=643 n=742 n=1385 % % % Used health facility Yes, survey 1 28.5 43.9 36.8 Yes, survey 2 20.2 34.8 28.0 Males Females Total Survey 1 n=166 n=298 n=1264 Survey 2 n=130 n=258 n=1385 % % % Used health facility for FP Yes, survey 1 1.2 14.4 3.6 Yes, survey 2 6.2 22.9 4.8 Used health facility for ANC Yes, survey 1 - 29.2 - Yes, survey 2 - 31.0 - Used health facility for trauma Yes, survey 1 44.6 30.5 13.1 Yes, survey 2 20.0 12.8 4.3
In summary, through the year of the EVD outbreak utilisation of health facilities decreased generally, but it appears that access to sexual and reproductive health was not impaired. More qualitative data would be required to better understand how this was possible.
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During and in the immediate post EVD outbreak there was a slowdown in CAGs community mobilization (village to village awareness raising) coupled with the limited support for outreach activities including provision of outreach materials – megaphone, batteries, torch lights etc. This has implication for community mobilization and CAGs visibility in the communities
The reasons for visiting the health facility (HF) are detailed in table 37. The majority of the reasons for visiting the health facility (91% in male and 54% in female) were not related to sexual and reproductive health. The first cause was malaria in both sexes. Because the HF was used mostly for curative motives it is possible that the positive opinions regarding youth friendliness and satisfaction in general was biased towards satisfaction.
Table 37. Reasons for visiting the health facility, young people 10-24 years - 2016 Reason for visiting the Total Male Female health facility Yes % Yes % Yes % Antenatal 1 0.6 80 20.2 81 14.5 Postpartum 1 0.6 31 7.8 32 5.7 Delivery 1 0.6 38 9.6 39 7.0 Family Planning 8 4.9 59 14.9 67 12.0 STI 15 2.5 4 1.0 8 1.4 Malaria 89 54.6 113 28.5 202 36.1 Trauma 26 16.0 33 8.3 59 10.5 Other 33 20.2 39 9.8 72 12.9 Total reasons for visiting 163 100% 397 100% 560 100%
The interviewees were also asked for their appreciation of the health facility services, in terms of quality of care, friendliness, respect and confidentiality. As in the previous survey, positive answers scored high. Interviewees were also asked on a scale from 1 to 5 if the services were “youth friendly”; again more than 85% answered much or very much. These results were compared to the objective criteria of youth friendliness assessed in the HF survey (§ 3.5). Approximately, one third (29%) of the visited health facilities had a separate room for the provision of these services and half had special sessions with youths.
Figure 9. Opinion of young people 10-24 on the services received at health facilities (%)
Figure 10. Young people 10-24 years saying the health services are youth friendly (%) (n=388)
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3.2.3 Questions about payment: rationale and results In survey 1, it appeared that costs were mentioned as a barrier to using the Family Planning services. On the other hand Family Planning services in Sierra Leone are in principle free of charge. This motivated us to add two questions: “did you EVER pay (or give a gratification) for Family Planning”. and if yes, “what did you pay for?”. The “ever” was added to allow people who had not used the services in the previous year to answer, and consequently the denominator is bigger than those who used services solely in the previous year.
Figure 11. Paying for Family Planning services (%) (n=1409)
In effect there were more who paid (14.8%) than who did not (10%). The reasons for payment (not mutually exclusive) were as follows: 88% paid for the commodity itself, 16% paid for the “clinic card” and less than 10% for other reasons including “gratification”.
3.2.4 Use of contraceptive methods during the EVD outbreak Among those who answered the question “Did you for any reason stop taking FP methods during the Ebola outbreaks?” one third (30%) referred they had done so. The most common reasons given for stopping taking contraceptives was fear of getting sick with EVD virus disease at the health facility. followed by being afraid of getting contact with patients and because the health facility was closed.
3.3 UNFPA interventions and adolescents and young population
All computations are made on the interviewed sample of 1409 individuals. UNFPA supports the implementation of three population targeted interventions and two interventions targeted to health providers, which will be discussed in the sections on health facilities. The three population oriented interventions are an educational radio drama: Saliwansai, the Restless Development voluntary peer
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 38 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone educators and the UNFPA supported community wellness advocacy groups. The first survey comprised 30 questions related to these three interventions. The present survey did not include the questions pertaining to Saliwansai as it was not on air the previous year. For better comparability, the questions pertaining to the interventions follow a common canvass: knowledge, appreciation, possible change induction. The interventions will be presented separately briefly. In survey 1 a major focus had been put on comparing their effectiveness. In survey 2, for reasons which are unclear, mixed influences, EVD outbreak, unidentified co-interventions, the comparison aspect seems less relevant, as there may well be a place for each of the interventions. The previous canvass has nevertheless been maintained with a comparison section.
3.3.1 Saliwansai This radio drama programme was not on air, therefore questions related to it were not included in this survey and therefore issues related to this intervention were not analysed in survey 2.
3.3.2 VPEs / attenuation – contamination of specificity of UNFPA interventions areas in survey 2 in comparison to survey 1 It is important to remember that since 2014, the design of the study was to over-represent “VPE exposed areas” (VPE+) to “VPE non-exposed areas” (VPE-) by 2:1. In this context, 918 (878 in survey 1) interviews were performed in VPE+ areas and 491 (411 in survey 1) interviews in VPE- areas.
In survey 1, the area concept worked effectively with over 40% exposure (answer “yes” to question: “ever met?”) to VPEs in VPE+ areas and only 10% in VPE- areas. However, the contrast is lost in survey 2 (table 38). This is presumably related to mobility, both of the population and of the VPEs. The loss of contrast has been carefully explored, in particular by examining results in each of the 48 clusters visited. There is no “clustering” or likelihood that this is related to errors in the interviewing or in the sampling procedure.
Table 38. Loss of contrast between VPE+ and VPE- areas between survey 1 and survey 2 UNFPA intervention CAG met VPE met area Denominator: n Denominator: n Year. type and n surveyed and Yes % [95% CI] surveyed and Yes % [95%CI] answered answered Survey 1 CAG- VPE- 258 12.1% [6.6 ;17.6] 259 10.4% [4.0;16.7] CAG+ VPE- 142 14.5% [2.6 ; 26.3] 141 9.3% [4.6;14.0] CAG- VPE+ 436 16.7% [9.1;24.3] 435 47.4% [37.6;57.2] CAG+ VPE+ 389 16.6% [8.6;24.6] 399 46.2% [37.0;55.4] Survey 2 CAG- VPE- 246 23.1% [11.7 ;40.4] 249 41.8% [7.5;86.3] CAG+ VPE- 237 13.7% [5.8 ; 29.0] 238 46.5% [7.9;89.8] CAG- VPE+ 432 26.3% [15.6;40.8] 423 54.64% [42.6;66.0] CAG+ VPE+ 479 16.6.(% [6.1;24.2] 479 36.1% [23.0;51.8]
Overall 44.6% (n = 619) of interviewees had encountered a VPE, which is a noticeable increase when compared with survey 1. Most people had more than one encounter.
Questions about satisfaction with VPEs scored high; 79% of interviewees mentioned they liked the encounters very much, and only one in 619 considered he/she did not like the encounters.
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As explained, the strata did not work properly on survey 2 compare to survey 1. This is why in this report, when relevant we looked at exposure to CAGs and VPEs rather than at strata.
3.3.3 UNFPA and enhanced CAGS
As has been mentioned in the introduction, Community Wellness Advocacy Groups, generally referred to by the population as “CAGs” have been established all over the country since 2010. The UNFPA intervention on CAGs aims to ensure a programme of continuing professional development, specific to certain UNFPA supported districts, and in addition to what is already provided by the MSWGCA for all CAGs. This means that exposure to CAGs occurs in all areas, but that there are in effect two kinds of CAGs: standard CAGs and UNFPA enhanced CAGs.
In survey 1, there was not much contrast between CAG+ and CAG- areas. In survey 2 (table 38), as for the VPEs the contrast is totally blurred so that it is valid to look at individual exposure but not anymore at UNFPA intervention areas.
In the household survey, overall CAG exposure was reported by 21.6% (n=299) of respondents, an increase compared to 15.5% in survey 1. It remains true that there is no visible difference between exposure to CAGs between enhanced and standard CAGs, so that the greater visibility of CAGs may be true for all types of CAGs.
As for the VPEs, most people exposed to CAGs, liked the programme. Questions about satisfaction with CAGs scored high; 72% (215) mentioned they liked the encounters “very much”. Only 2.3% (7) considered they did not like the encounters at all.
CAGs are also able to send a person to a health facility with a referral slip. This was also explored.
3.3.4 Comparing the two interventions (VPEs and “enhanced CAGs”) and change in time The two interventions have a common goal of health promotion and empowerment, with a specific focus on reproductive health and gender issues, including delayed childbearing and education. For this reason, it appears more useful to present the characteristics and the impact of the two interventions together. However, it is of importance to keep in mind that they are not targeted to the same population, with broadly: VPEs are targeted to young people 10-24 yrs, and CAGs targeted for women in general and particularly women in reproductive age. The means are also not in the same order of magnitude, with VPEs having a more robust infrastructure.
Regarding the exposure and the perception of the UNFPA supported interventions, as assessed by the household survey, there have been at least 3 important changes between survey 1 and survey 2:
I. The radio programme Saliwansai was no longer on air; II. The contrast in exposure between intervention areas has disappeared; and III. Many more people are exposed (generally), especially for the VPEs.
In survey 1, with 3 interventions (Saliwansai radio programme, VPEs and enhanced CAGs), exposure to each of the three interventions was of the same order of magnitude, between 12% and 20% of interviewees having been exposed to these interventions. In survey 2, Saliwansai was not on air anymore, therefore it was not measured. Exposure rate to CAGs had increased from 15% in survey 1 to 19% in survey 2. VPE exposure increased, almost doubled, from 24% in survey 1 to 44% in survey 2. Appreciation of both VPEs and enhanced CAGs is high in survey 2, as it was in survey 1 (fig 12).
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Figure 12. Appreciation of the interviewees (10-24 years) on each of the interventions (%), survey 2
There is a slight preference for the VPEs, which was already observed in survey 1. The same trend was observed in the questions: “did it Influence you to think differently” and “did it Influence you to act differently”. However, in terms of influence to use Family Planning there was no superiority of one or other intervention (fig 13).
Figure 13. Influence of intervention on seeking Family Planning services, by sex (%), survey 2
Answers “yes very much” and “possibly in part” were summed as “the intervention influenced you”. Values are very similar to those of survey 1.
Another important aspect is the topics addressed by CAGs and VPEs. The interviewees reported having heard about the following topics (fig 14) from each of the actors of the interventions.
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Figure 14. Topics addressed by VPEs and CAGs (%), survey 2
%
Many important topics have been addressed. The three highest ranking topics addressed by VPEs are early marriage, school retention until 15 years and malaria / bed nets. For CAGs the three most frequently addressed topics are early marriage, giving birth at the health facility and malaria / bed nets. Two topics are common to the two types of interventions: “not marrying too early (early marriage)” and “malaria prevention”. It is noteworthy that there has been, between the two surveys, a marked increase in use of mosquito nets (49% to 69%, §3.1.2.3). The encounters with CAGs and VPEs may have been instrumental in this advance. The topic that is common among the three highest ranking is appropriately related to the target population: staying on at school for VPEs, and giving birth at the health facility for CAGs. For all topics except giving birth in the health facility, there was a larger percentage of VPEs than CAGs who were reported to have discussed the topic. In addition, it must be remembered that exposure to VPEs was more likely so that the absolute effect is greater even when percentages are of the same order of magnitude.
The topic “cholesterol” was included, already in 2014, to identify whether interviewees were answering indiscriminately “yes” to all topics. The very low results for cholesterol suggest that interviewees were answering validly.
The topic Ebola was new to survey 2, 44% of the interviewees reported having heard about this topic from CAGs and 58% have heard about it from VPEs.
It was satisfactory to compare the results of the two surveys. The percentage of interviewees having heard about the topic increased for almost all topics, and for both VPEs and CAGs. The two
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 42 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone exceptions were STI in VPEs and fistula in CAGs. Topics “staying on at school” and not marrying too early were the two most marked increases.
3.4 The provision of FP services by the public health facilities
This section presents findings from the health facility survey.
3.4.1 Availability of contraceptive commodities at the health facilities on the day of the facility audit According to the Sierra Leone Basic Package of Health Services all type of health facilities should distribute male and female condoms, oral and injectable contraceptives. Insertion of intrauterine devices (IUDs) and implant should be done at hospitals and under supervision at CHC. Permanent surgical methods should be carried out at hospitals (all other health facilities should refer to the hospital for these services).
We inquired about the availability of contraceptive methods on the day of the visit. The interviewers were told to ask the question and actually observe if the methods were available at the facility on the date of the visit. On the day of the visit, combined injectable, progesterone only pill and combined oral contraceptive pills were available in more than 80% of the health facilities reporting on this item, similar to survey 1.
Table 39. Availability of contraceptive methods in the health facilities surveyed on the day of the visit
Availability on the day of the visit Survey 2 Survey 1 Contraceptive methods N Yes N Yes n n % n n % Combined oral contraceptive pills 109 91 83.5 110 105 95.5 Progesterone only pill 109 108 99.1 110 105 95.5 IUD 109 46 42.2 64 43 67.2 Combined Injectables contraceptives 109 105 96.3 109 100 91.7 Progestin-only injectable contraceptives 109 3 2.8 39 3 7.7 Implant 109 81 74.3 83 66 79.5 Male Condoms 109 109 100.0 106 102 96.2 Female condoms 109 66 60.6 86 73 84.9 Spermicide 109 0 0.0 Female sterilisation 109 5 4.6 32 5 15.6 Vasectomy 109 2 1.8 25 1 4.0 Note: female sterilisation and vasectomy should be offered only by hospitals
3.4.2 Without stock-outs of contraceptive commodities in the health facilities in the last six and three months A continued supply of contraceptive methods at the health facility reduces the possibility for missing opportunities. We also inquired about whether or not the health facilities have experienced no stock- out of contraceptive commodities in the last six and three months. For 8/12 contraceptives commodities inquired there was for each of them the same or an increased number of health facilities reporting not having stock-out of contraceptive commodities in the last three months as compared with the last six months, which may be indication of a continued supply of these commodities.
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Table 40. Percentage of health facilities without stock-out of contraceptives in the last six and three months Without Stockouts - Survey 2 For last 6 months For last 3 months Contraceptive methods N Yes N Yes n % n % Combined oral contraceptive pills 109 84 77.1 109 93 85.3 Progesterone only pill 109 105 96.3 109 104 95.4 IUD 109 45 41.3 109 46 42.2 Combined Injectables contraceptives 109 96 88.1 109 104 95.4 Progestin-only injectable contraceptives 109 4 3.7 109 4 3.7 Implant 109 62 56.9 109 75 68.8 Male Condoms 109 103 94.5 109 105 96.3 Female condoms 109 69 63.3 109 70 64.2 Spermicide 109 0 0.0 109 0 0.0 Female sterilisation 109 5 4.6 109 4 3.7 Vasectomy 109 3 2.8 109 3 2.8 Note: female sterilisation and vasectomy should be offered only by hospitals
There appears to have been an improvement on the supply and availability for certain contraceptive commodities when we compared health facilities without stock outs of contraceptive commodities in the last three months in survey 2 and in survey 1. In survey 2, for most contraceptive commodities, there is a larger number of health facilities reported not having stock outs in the last three months when compared with survey 1 (table 41).
Table 41. Percentage of health facilities with no-stock out of contraceptives in the last three months, 2016 and 2014 Without Stockouts in the last three months Survey 2 Survey 1 Contraceptive methods N Yes N Yes n % n % Combined oral contraceptive pills 109 93 85.3 110 89 80.9 Progesterone only pill 109 104 95.4 IUD 109 46 42.2 53 39 73.6 Combined Injectables contraceptives 109 104 95.4 109 86 78.9 Progestin-only injectable contraceptives 109 4 3.7 24 13 54.2 Implant 109 75 68.8 81 59 72.8 Male Condoms 109 105 96.3 109 86 78.9 Female condoms 109 70 64.2 84 62 73.8 Spermicide 109 0 0.0 20 12 60.0 Female sterilisation 109 4 3.7 23 14 60.9 Vasectomy 109 3 2.8 16 10 62.5 Note: female sterilisation and vasectomy should be offered only by hospitals
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We also analysed the number of health facilities without stock out of modern contraceptives (excluding female sterilisation, vasectomy and progestin-only injectable) in the last three months and six months. Similar results were observed for both periods in survey 1 as well as in survey 2.
Table 42. Percentage of health facilities without stock-outs of modern methods of contraception in the last six months
Without Stockouts in the last 6 months Survey 2 Survey 1 N Yes N Yes Contraceptive methods n % n % Modern methods (except for female sterilisation, 109 109 100.0 110 105 95.5 vasectomy and progestin-only injectable) 3.4.3 Combination of Family Planning services being provided There has been an increased in the mix of FP services offered at health facilities in comparison with survey 1. When asked about which Family Planning services are offered, 5% of the health facilities were offering services for at least three methods29 (100 % of health facilities in survey 1), 12% (10% in survey 1) were offering four methods, 25% (39% in survey 1) were offering five methods and 58% (50% in survey 1) were offering 6 or more methods. In survey 2 the mean numbers of family services offered was 5.6, the median 6 (range 3 to 9).
3.4.4 Equipment items The availability and functionality of equipment for the provision of Family Planning contributes to quality of services. Out of nineteen basic equipment items inquired, nine30 were available in 80% or more of the health facilities visited (12/19 equipment items available in 80% or more of health facilities visited in 2014). A few items were not available in 40% or more of health facilities including flashlight, standing lamp, tenaculum, speculum, xylocaine or lidocaine 1% without adrenaline, disposal containers for contaminated waste/supplies. See annex 7 for a detail list of equipment items availability.
The availability of three items for provision of implants (implant kit, sterile gloves, Xylocaine or Lidocaine) at hospitals and CHC was assessed. These three items were available in 67% of hospitals and 53% of CHC at hospitals (a decline from the findings in survey 1 where the three items available in all hospitals and 71% of CHC).
The availability of 5 items for the provision of IUD (specula, tenaculum, scissors, flashlight, standing lamp) at hospitals and CHC was also assessed. These five items were available in all hospitals and in 71% of CHC. This represents an improvement from the availability reported in survey 1 (22% of hospitals and 4% of CHC).
3.4.5 Human resources for the provision of Family Planning services The availability of human resources in adequate numbers and with the proper skills for the provision of services is essential to quality care. Aproximately half (45%) of the health facilities surveyed had at least one member of staff trained in AYF services (up from 32.8% in 2014).
29 The methods inquired include: female sterilisation, vasectomy, implant, IUD, Combined oral contraceptive pills, progesterone only pill, combined injectables contraceptives, progestin-only injectable contraceptives, male condoms, female condoms, spermicide 30 These items are: stethoscope, scissors, forceps (mosquito), sterile gloves/surgical gloves, sharp containers for used sharp, plastic buckets or containers for decontamination, instrument tray, bowls or galipot, antiseptic solution.
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In the health facilities surveyed three cadres are more frequently assigned for the provision of Family Planning services. Maternal and child health aides were assigned to provide these services in 83% of health facilities surveyed, SECHN in 56% and Community Health Officers in 46%. These cadres have been targeted for training in long term methods since the Ebola outbreak. However, training activities are not necessarily targeted to those currently assigned to provide the Family Planning services. For example, 23% of health facilities had at least one CHO trained on long term methods (LTM). Similar training gaps as those observed in survey 1 remain. More training efforts are required to ensure adequate coverage of health facilities with trained staff for the provision of long term methods.
Table 43. Percentage of health facilities with at least one staff per category providing FP services or trained in LTM per staff category
3.4.6 Management and logistics In 63% of the facilities surveyed, the replacement time for contraceptive commodities the last time the facility run out of them was less than a month. In general the replacement time was three months or less in 93% of the health facilities (similar to survey 1).
In more than 90% of health facilities contraceptive pills and male condoms were stored both protected from the rain as well as off the floor/ on shelves (in more than 80% of health facilities in survey1). These conditions were less favourable for the storage of IUDs and implants. Implants were stored protected from the rain and off the floor/ on shelves in 73% of health facilities. IUDs were stored protected from the rain and off the floor/ on shelves in approximately 40% of health facilities. In summary, in comparison with survey 1 the storing conditions for contraceptive pills and condoms appears to have improved. The storing conditions for IUDs and implants are similar to the findings of survey 1.
3.4.7 The Family Planning client – provider encounter
3.4.7.1 Provider’s counselling skills The quality of the counselling skills was assessed using eight “actions” the health providers should perform during the counselling session. The median number of actions performed was seven for all staff categories. Annex 8 presents the number of actions performed by staff categories.
The content of the counselling session was assessed through whether or not a number of topics were addressed during the session. The providers were covering these topics far less consistently than the eight actions for good counselling, as shown in the table below. Issues related to sexuality were
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 46 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone discussed less frequently (history of pregnancy complications, timing of next child, multiple/single partners, desire for more children). Similar findings were reported in 2014.
Table 44. Provider´s action during the counselling session, survey 2
On other actions considered particularly important for new clients, the providers performed well, as shown in the table below. These findings are also similar to those reported in survey 1.
Table 45. Percentage of FP users (clients) who were informed about the effects or problems of methods selected. for women 15-49 years (among new clients only), survey 2 As reported by client Variables (N=98) As reported by observer (N=93) Percentage of FP users (clients) who were informed about side effects or problems of methods used (new clients only) n Yes n(%) N Yes n (%) Explains how to use selected method 79* 76(96.2) 93 90(96.8) Explains side effects of method selected 80** 73(91.1) 93 88(94.5) Explains what to do in case of problems 80** 76(94.9) *18 missing.1NA; **19 missing
For new clients only, we also analysed if they were provided information on the method accepted related to both side effects of the method selected and what to do in case of problems. A total of 77% of clients were informed of these two issues, a decrease when compared to survey 1 (99%).
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Table 46. Percentage of FP users (clients) who were informed of both side effects of method selected or what to do in case of problems, for women 15-49 years (among new clients only), survey 1 and survey 2
Survey 1 (N=101) Survey 2 (N=94) n Yes, n (%) n Yes, n (%)
Explains side effects of method selected or what to do in case of problems 101 100 (99.0) 94 73 (77.7) 3.4.7.2 Infection prevention procedures Compliance with specific infection prevention procedures required for the provision of injectable and pelvic exams were determined through the observation of clinical procedures. Except for dropping needle into a safety box, the majority of providers followed the infection control procedures for injectable. All infection prevention procedures inquired were followed in the pelvic examinations observed. However, only a few pelvic examinations were observed, it is therefore not possible to draw conclusions. The information on their observation is presented below for illustration purposes.
Table 47. Percentage of providers who follow infection procedures, survey 2 Observation Providers who follow infection prevention procedure n % Injectable. n=93
Wash hands before injection 79 84.9 Used a disposable autodestruct syringe and needle 92 98.9 Drop needle into a safety box 42 45.2 Pelvic Exams. n=11
Washing hands 11 100.0 Put on new or disinfected gloves before exam 11 100.0 Use sterilised or high-level disinfected instruments for each exam 11 100.0 Ensure that instruments and reusable gloves are decontaminated 11 100.0
A new question was added to ascertain if the staff members of health facilities are cleaning instruments before decontaminating them (a new instruction given to them during the EVD outbreak). With the exception of one facility, this practice is currently performed in all the health facilities visited.
3.4.7.3 Client´s perceptions of the Family Planning services received The perceptions of Family Planning clients regarding the services received were positive. More than 90% of the clients felt comfortable to ask questions during the Family Planning encounter with the provider, thought that the amount of information provided during the session was good or very good and that they were treated well or very well by the main health care provider. A similar proportion of clients expressed that they thought that the information shared with the provider will be kept confidential and that no other clients could hear what was said during the encounter. Similar findings were reported in survey 1.
3.4.7.4 Correct actions observed during the application of contraceptive methods A list of procedures to check when observing clinical procedures during the Family Planning client- provider encounter were given to the observers. The list was developed based on the National Family Planning Manual for Service providers, July 2013. A total of 93 applications of injectable, 16 insertion of implants and 11 pelvic examinations were observed. For application of injectable 6/8 procedures observed were performed by 85% of more of the providers. As for the insertion of implants 10/14
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 48 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone procedures were performed by all providers and 4/14 procedures were performed by 80% - 94% of providers. In summary, the great majority of providers are following most of the established procedures for application of injectable and insertion of implant.
3.4.7.5 Paying for the Family Planning consultation on the day of the interview This was new question introduced in survey 2. Seven percent (15/211) of the Family Planning clients interviewed reported having paid some fees for the Family Planning consultation received on the day of the interview. Five clients referred having paid for the Family Planning method and 10 paid as an “appreciation” for the care provider.
3.5 Adolescents and youth friendly services
3.5.1 Standards for the provision of adolescent and youth friendly services The government is encouraging health facilities to be upgraded to provide adolescents and youth friendly (AYF) services and it is also training staff on the provision of these services. We inquired about selected criteria listed on the National Standards for Adolescents and Youth Friendly services (MOH SL, 2011). 13/14 criteria inquired were met each of them by 50% of more of the health facilities surveyed. This is an improvement when compared with the findings of survey 1, where 7/14 criteria were met by 50% or more of the health facilities. Improvements can be seen primarily in the criteria related to privacy of the consultation room and community participation.
Table 48. Existence of selected criteria for adolescents and youth friendly services, survey 2 Health facilities
Selected criteria for youth friendly services N n % IEC materials availability. IEC on FP for adolescents and youth 90 89 98.9 IEC on teenage pregnancy 90 81 90.0 IEC on STI/HIV 90 66 73.3 IEC on prevention of gender based violence 90 56 62.2 National standards book. observed Standards book available and observed 109 33 30.3 Service delivery point organisation Provide services in separate room 109 32 29.4 Special sessions with young people 109 57 52.3 Special arrangements for young females 109 60 55.0 (married. pregnant. lactating) Privacy Consultation room offers privacy 109 57 52.3 Community participation Traditional leaders sensitised on adolescents SRH 109 77 70.6 Parent´s association sensitised on adolescents 109 73 67.0 SRH CHW sensitised on adolescents SRH 109 86 78.9 CAG oriented on their role towards adolescents 109 86 78.9 and young people Data on young people shared with communities 109 56 51.4
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3.5.2 Human resources for the provision of adolescents and youth friendly services The survey inquired about the availability of 8 different staff categories per facility, their assignment to actual provision of services for adolescents and young people and whether or not they have been trained on AYF service provision since the EVD outbreak31. Four out ten health facilities visited (45%) had at least one staff trained in youth friendly services. This is an increase in relation to survey 1, where three out of ten health facilities visited (33%) had a staff trained on youth friendly services.
Table 49. PHU having at least one member of staff trained in youth friendly services, survey 1 and 2
Survey 1 ( N=110) Survey 2 (N=109) n % n % Visited facilities which have at least one member of staff trained in AYF services 42 32.8 49 45.0
Hospital 6 14.3 6 12.2 Community Health Centres 23 54.8 22 44.9 Community Health Posts 12 28.6 20 40.8 Maternal and Child Health Posts 1 2.4 1 2.0 Total 42 100.0 49 100
Table 50. Percentage of health facilities with at least one staff per category providing services for adolescents and young people or trained in adolescents and youth friendly services, survey 2
As can be seen in the figure below, maternal and child health aides, state registered nurses and community health officers were most likely to be assigned to the provision of services to the young. These staff categories have also been targeted for training on adolescents and youth friendly services, however important training gaps remain.
31 Survey 2 inquired only about training received since the outbreak of the EVD til December 2015, as it was measuring what has happened since survey 1
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Figure 15. Percentage of health facilities having at least one staff per category providing AYF services or trained on AYF services since the EVD outbreak, survey 2
5.5 Administrative Staff 14.7 1.8 Nurse Aid 7.3 33.9 Maternal and Child Health Aide 66.1 1.8 State Enrolled Community Health Nurse 2.8 22.0 State Registered Nurse 43.1 24.8 Community Health Officer 35.8 17.4 State certified midwife 24.8 0.9 Medical Doctor 0.9 0 10 20 30 40 50 60 70 Percentage of health facilities
Trained in AYF since ebola Providing AYF services
3.5.3 Number of service delivery points (SDP) upgraded to provide "adolescent and youth friendly services” This indicator is used to determine the basic capacity of the health facilities to provide youth friendly services. The SDPs upgraded to provide “youth friendly services” should fulfil the following criteria: i) having at least one trained health worker in adolescents and youth SRH. ii) privacy and confidentiality honoured and iii) education material available onsite. Approximately one third (30%) of the health facilities surveyed fulfilled these criteria (up from 10% in 2014).
Table 51. PHU upgraded to provide youth friendly services Survey 1(N=110) Survey 2(N=109) Variables n % n % PHU upgraded to provide youth friendly 11 10 33 30.3 services (composite )1 Hospital 2 18.2 1 3 Community Health Centres 7 63.6 18 54.5 Community Health Posts 2 18.2 14 42.4 Maternal and Child Health Posts 0 0 0 0 Total 11 100 33 100 1facilities should fulfil the following 3 criteria: i) At least one trained health worker in adolescents and youth SRH ii) privacy and confidentiality honoured iii) education material available onsite
3.6 Focus group discussions
The findings of the FGD are summarised below.
3.6.1 Most common health/social problems affecting young people The majority of the participants were generally aware of the health and reproductive problems in their respective communities; however, those in the age category 20-24 years, both male and female, were more responsive to these problems. Most of the participant mentioned poverty as the main social problem affecting young people, leading to early marriage (as this way the man can take care of providing for the needs of the girls and her family), early pregnancy and abandoning school. It
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 51 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone is not surprising that across all age groups, teenage pregnancy, early marriage, and STDs were mentioned by the majority of participants as the most pressing health problems affecting young people.
“For me poverty is the main problem because poverty makes us discontinue schools and it also makes us to have relationship with different men because we need people that can take up our responsibility, men that can feed us and our parents, as for me at one time me and my mom got a serious problem because there was no money at home and she wanted me to go to my boyfriend and beg him money which I denied to do.” (Female 20-24, Kenema).
“Teenage pregnancy is the problem that is most serious in this community because most of the girls in this community have given birth to two or three children and they are no more going to school and I think this is happening because they don’t have better understanding on what to do not to get pregnant.” (Male 15-19, Moyamba).
Most participants were of the opinion that social and health problems affect more girls than their counterpart boys. This is because women / girls have little knowledge of Family Planning methods and reproductive health, which lead them to having sex and get pregnant at early age. If a girl engages in sex, she can get pregnant and has to abandon school. If the boys / men have sex and they get a girl pregnant, they can still continue going to school. According to the participants, when girls engage in sex they can experience bleeding and vaginal pains, boys can get sexually transmitted infections.
“The young girls are affected the most, because young boys if they get a girl pregnant, they can still continue their school but the girl cannot continue her school since she is pregnant.” (Male 15-19, Kambia)
“For me, it affects girls especially age 10-19 because we lack the experience to handle delicate Family Planning issues” (Female 15-19, Kambia).
“It affect we the boys (15-19yrs) because some of us are actively involved in sex at this age, by so we impregnate lot of girls and get infected with STIs at this age.” (Male 15-19, Moyamba)
When the participants were asked about what can be done to improve this situation, the majority mentioned that the government should take action such as, providing jobs for the parents to allow them to care of the needs of their children and therefore preventing them from early marriage and early pregnancy; making Family Planning methods available for free to all teenagers and to ensure that the education system embarks on sensitisation on the use of Family Planning methods to avoid teenage pregnancy.
3.6.2 Age of sexual initiation for boys and girls, and how decisions are made to engage in sex The majority of the participants were of the opinion that secondary school should be finished first before starting sex, which according to them is most times after the age of 18/19 for boys and girls. At this age they will be matured to be involved in sexual intercourse and to handle the risk and prevention for certain health problems. Most boys and girls participating in the FGD, thought that at this age the time is ripe and they have the right to have sex.
“18-19 years is the time I think we should begin to have sex because that is the time we are matured and we will not have any after effects.” (Female 10-14, Kenema).
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Reasons/decisions to engage in sex Several reasons leading to engaging in sex were given. For girls within ages 10-14 years peddling in the street pushed them into sexual activity, most times beyond their wish. For girls, the arrival of menstruation for girls is also a common reason why girls start sex at an early age as most participants believed that menstruation is a ripened stage for any girl to involve in sexual intercourse. The participants also expressed that girls make a decision to have sex at the age when they start experiencing secondary growth characteristics like development of the breast, buttocks, hair growth in private areas like armpit, Likewise, boys felt that the growth of pubic hair gave them the desire to start sex or made them feel ready to have sex.
“Some girl child starts sex from 13-14 years for instance if the girl child is doing a street trading the boys will persuade them with money to have sex with them.” (Female 10-14, Kambia).
Peer group influence is another factor for both boys and girls becoming involved in sexual activity. A few participants especially those in the age category of 20-24 years expressed that their peers sometimes compelled them to involve in sex or provoked them about their non-sexual activity. These participants felt that their decision to start sex is influence by their peer urges.
“I started having sex when I was 14 yrs. old and I involved in it because my friends influenced me, they were mocking me because they had already had sex before that age and for them they had sex at that age because of money, they wanted money to buy clothes and other things.”(Female 20-24 Kenema).
Few participants believed that boys who had access to films or phones containing sexual activities gave them the exposure and understanding which makes them engage in sex.
Male participants especially those in the ages of 10-14 mentioned that having wet dreams at night and sleeping in the same room as their parents are some of the factors that bring out the desire to have sex with women. Participants on this age group also expressed that the size of their penis and the sight of an undressed girl or woman gave them sexual feelings and longing to fulfil such desires.
3.6.3 Knowledge and use of condoms The majority of the participants in all categories and areas were knowledgeable about condoms and its use. The participants mentioned that condom is being used for the protection of STIs and mainly for prevention of pregnancy. When asked about the decision on whether or not to use condom or not during sex the female 10-14 years were less active in the discussion because most of them claimed that they had never been involved in any sexual intercourse therefore they did not know much about condoms. However, boys in this age category pretend to know more about condom than their female counterparts.
“What I know about condom is that if you are having sex with your partner and you do not want to be pregnant, you can use it for protection.” (boy 10-14, Kambia).
The participants in the age category 20-24 years emphasized the uses and benefits of condom and their understanding about it. Most of the participants believed that condom is very useful in terms of disease prevention and birth control.
“I have seen condoms many times in fact it is the most common Family Planning method available because it easy to get and when you use it, it will prevent you from both sickness and pregnancy.” (Female 20-24, Moyamba).
Decisions on the use of condoms The decision to use condom when engaging in sex can come from both the boys/men or the girls/ women, and is primarily used to prevent pregnancy. In some cases, it is the male partner actually
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 53 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone deciding to use condom especially when the girl still attends school. However, it was agreed that in most cases it is the women deciding to condoms.
“Women decide because I have the experience with about 70 percent of women who had asked me to use condom because they do not want to be pregnant.” (Male 20-24, Moyamba).
The participants gave various reasons on how they felt about condoms and why they sometimes hesitated to use it. The participants especially girls expressed fear that if they consistently use condom they will not be able to become pregnant at a later time. Few other girls mentioned that they were afraid of using condom because it will get stocked in their stomach especially when they had sex with rough partners, which could be very dangerous. Other participants expressed that they do not use condom because they thought that the oily substance on the condom is dangerous. The participants also mentioned that if they wanted to get pregnant or wanted to enjoy real sex they avoided using condoms.
Source of Information on the use of condom Restless Development, Marie Stopes, school teachers, government hospital/health centres, media, and community elders were mentioned as the main sources of information about condoms. The participants expressed that the information provided helped them because it has reduced teenage pregnancy, reduced the rate at which people contract STIs, reduced drop out from school (because girls do not get pregnant, if condom is used). The participants were of the opinion that a condom is a relatively cheap Family Planning method. The participants also referred that they were informed and educated about condoms being free of charge.
“The hospital gives advice about condom especially during the outbreak of the Ebola we were advice to use condom for safe sex.” (Male 20-24, Moyamba).
3.6.4 Modern and traditional birth control methods The participants in all age categories were aware of captain band (implant), depro injection, condoms, pills (tablets), traditional rope, and coil (IUD) as birth control or Family Planning methods. They had different views about modern and traditional birth control methods particularly the girls/women. Nonetheless the majority of the female participants in all age group preferred condom use (it is relatively easy and cheap to get compared to the other birth control methods), and pills/tablets. They thought its use posed no harm.
The participants had different views about their preferred methods and their respective effectiveness. Nonetheless, the male participants were more aware about condoms as compared to the other birth control methods, whilst the female participants had diverse awareness about birth control methods ranging from modern to traditional means. The participants considered the modern methods as the most effective and preferred methods because of their reliability. They saw the traditional method as difficult to maintain because of the many restrictions pertaining their use.
“My aunt tells me about birth control methods, she was the one that introduced the traditional rope to me which is worn around the waist, even though I don’t use it normally because of it many laws like when you have the rope on you should not look at a corpse.” (Female 20-24, Kenema).
A few participants, especially the boys/men, were of the opinion that instructions for the use of a traditional rope is not clear as compared to modern birth control methods.
A few female participants expressed fear of using condom. They felt that some boys/men could be wicked by trying to tear the condom in order to get them pregnant. They also expressed that some boys/men are rough and they fear that the condom would be left inside of them. They also believe
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 54 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone that the lubricant on the condom could be harmful. There was a female participant expressing that the condom could be fatal and dangerous so she preferred using birth control pills instead.
“I do not like to use condom because one of my friends died through the use of condom, it got stocked in her stomach.” (Male 20-24, Kenema)
Girls/women oppose the use of captain band and coil because they believe the captain band and coil were dangerous for the inner skin. They also mentioned other side effects of captain band like wound, swollen stomach, bleeding and sometimes headache. As for the coil, participants believed that consistent use would make the womb infertile, and thereby making it impossible to give birth again.
“Captain band is very dangerous because most of the time it gets broken inside our colleague’s hand.” (Female 20-24, Kenema).
The participants also expressed some risks involved in using IUD, which they thought could create problems in their stomach especially if they met with different men.
“The coil is dangerous because they used to tell us that whenever a woman gets it inserted in her, she should only sleep with one man, and if she eventually sleeps with another man with a bigger and longer penis, he will shift the coil deeper into the woman’s stomach which is very dangerous for her health.” (Female 15-19, Moyamba).
3.6.5 Engagement with partners/ parents on the decision to use Family Planning methods Parents, school, health programs broadcasted on radio, explanation at the pharmacy and sensitization from health workers, NGOs like Marie Stopes, Red Cross Society and Restless Development are the sources from which young people get information on Family Planning methods. Most participants believed that they received reliable information from these channels.
Most girls/women participants within the ages 15-19 and 20-24 years expressed that they consult with their partners to decide which Family Planning method to use.
“My own partner prefers condom, because he does not want me to use any other method that will create problem for me.” (Female 15-19, Moyamba).
A few participants in the age group 15-19 years mentioned that they seek advice from their parents in order to decide about the Family Planning method that would be suitable for them. The participants also mentioned that their relatives, like aunts, are involved and assisted them with this decision. Others expressed how teachers assisted and advised them on which Family Planning methods to use.
“I will feel free to ask my parents to use condom because I do not want to get pregnant or sicknesses.” (Female 10-14. Kenema). “For me, it’s my Aunt that gave me information about Family Planning she even went with me to Marie Stopes when I took captain band in Kambia.” (Female 20-24, Kambia).
3.6.6 Cost associated with getting Family Planning services Most girls/women participants expressed they have paid money ranging from Le 5,000 to Le 20,000 (USD 1.2 to USD 5) for captain band, coil (IUD), injection and pills. They paid for such services and items at the health centre or pharmacy. Sometimes they give healthcare workers a token for providing them treatment. A few participants claimed not to have paid anything for Family Planning services when they got these services from Marie Stops in their communities.
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“For the Depro we pay the sum of Le3, 000 and we buy needle and syringe at Le1, 000 and give the nurses something for injecting us.” (Female 15-19, Moyamba).
“The health staff always encourages me to take the captain band, though they will later ask me to pay Le 10,000.” (Female 20-24, Kambia).
“Most of the time Marie Stopes supply condoms especially to the boys but for us the girls they come with captain band so we can fix it for free.” (Female 20-24, Kenema)
The participants in all groups agreed that condom was the cheapest and virtually free Family Planning method, and as a result they had access to condom anytime they decided to use it. The boys/men also felt that condom is the best way to prevent their girlfriends from getting pregnant when they are still at school.
“For me, my friend who is working at the hospital supplies me with condom and I have never paid for it” (Male, 15-19 Kambia).
3.6.7 Information regarding Family Planning and Reproductive Health The majority of the participants mentioned that various organizations including Marie Stopes, Restless development, Care International, Red Cross, as well as relatives, had been providing them with information regarding Family Planning and reproductive health. The participants expressed that most of the information and advice provided was primarily centred around the importance of protecting against early marriage, and early / unintended. They highlighted that this information helps them to plan for a better future, and the advice provided was also in line with the expectations of their parents for them to abstain from sex.
A few participants also mentioned that their parents are playing key roles in discussing Family Planning and sexual and reproductive issues. According to these participants, the discussions were mainly to dissuade them from engaging in any form of sexually activity. A few of the participants expressed that this support had helped in building them morally and preventing them from giving birth at an early age.
“We get regular discussions with our parents and their main focus is for us to avoid sexual activity.” (Female, 15-19, Moyamba).
Other information received from the above mentioned sources includes: the use of condoms during sex to protect young girls from getting pregnant, the use of birth control methods will enable them to space and plan their families, avoiding pregnancy before age 18 will prevent complications during delivery, a girl over 18 is better prepared to take care of a young child, advice not to give birth to more than 3 children and space them properly.
Usefulness of Family Planning and reproductive messages Most participants in all age categories highlighted that the information they received has helped greatly in reducing the rate of teenage pregnancies, in STIs prevention with the use of condoms, in avoiding trouble with the law especially for young men getting young girls pregnant, in giving them sound knowledge on birth control methods, in helping them to plan on their future child birth, and in preventing them from dropping out of school early because of teenage pregnancies.
Information regarding early marriage The majority of the participants mentioned that information on early marriage was mostly discussed on the radio, and they expressed that the discussions focused on early marriage as a crime. According to the participants, early marriage will destroy the future of those given out in marriage at
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 56 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone an early age, as this leads to dropping out of school early and giving birth to an unplanned number of children.
A few of the participants mentioned that issues related to marriage are also discussed among the community. The discussions relate to concerns for the welfare of both the male and female individuals entering into early marriage without proper understanding on what it takes to be married and being unable to provide for themselves and their children. The participants also expressed that early marriage will lead to premature death especially for the mothers who are physically ready to deliver babies.
3.6.8 Health seeking practices and behaviours The majority of the participants identified PHUs, Marie Stopes, Restless Development and community health workers as the main sources for obtaining Family Planning and reproductive health services.
“If we needed advice or services for our wives or girlfriends on Family Planning, we will go to the hospital, and at times the nurses came to our community to talk to people about Family Planning.” (Male 15-19, Kambia).
The likely ways to get a condom when they need one include: buying from the pharmacy, getting supplies from the hospitals, Marie Stopes, Restless Development and/or from Plan Parenthood Association. According to the participants it was easy to obtain Family Planning birth control pills and condoms from the health facilities
“If we needed anything on Family Planning, birth control, or any other thing relating to sexual health, we go to the hospital, because the medications are there, very easy to get and the nurses are trying their best to ensure that they are put to use.” (Male 15-19, Kambia).
Discouraging factors in getting contraceptives The majority of participants mentioned gossiping from community members and having to pay money for contraceptive services as factors discouraging them from getting contraceptives if and when they needed to.
“One of the things that discourages me is the gossip, when those Maries stopes people come here with their van if someone walk up to them and ask them for contraceptives then people in the community will gossip you.” (Female,15-19, Moyamba).
Also a few of the participants expressed fear and the negative thought most people associate with the use of contraceptives. According to the participants, some people are saying the use of contraceptives will have negative side effects when they are finally ready to get pregnant. Additionally, a few of the participants were very concerned with their privacy especially at the government hospitals. Most of these participants felt that Marie Stopes services can treat their case more confidential than the government hospitals.
“Some people usually have the negative thinking that it has side effects or at times they don’t get pregnant again once they stop using it.” (Male 10-14, Kenema).
“I do not even go to the government hospital. There is no confidentiality I only go to Marie Stopes since they maintain confidentiality.” (Male, 20-24, Moyamba).
The majority of the participants were satisfied with the way they were treated in health facilities, especially by the nurses whenever they visited health facilities for Family Planning services.
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“The nurse that gave me the captain band treated me nicely, at first I was ashamed but later I became confident and we interacted in a professional way. (Female, 20-24, Kambia).
Sex/age of health care providers as a factor in getting Family Planning The majority of the participants expressed a preference for getting Family Planning services from experienced and older health providers as compared to young and relatively inexperienced ones. According to these participants, older and experienced health providers treated them nicely, and gave good lectures on the dangers of early marriage and teenage pregnancies. On the other hand, they were treated like children by the younger health providers. who are mostly aggressive when dealing with them especially when it comes to Family Planning issues.
“The aged nurses usually treat me nicely at the hospital since they do not want us to bear children before marriage but the younger nurses are not accommodating, they talk to patients aggressively.” (Male 15-19, Moyamba).
A few of the participants especially females, expressed a preference for a women health provider for Family Planning and reproductive health services. A woman provider will make them very comfortable and not ashamed in seeking Family Planning services.
“All the nurses are women so I am not ashamed of any of them and that encourage me to always go there because I feel safe with nurses that are women.” (Female, 20-24. Wanjama, Moyamba).
3.7 Outcome and output indicators
In this section we provide an overview of relevant outcome and output indicators, not discussed in previous sections.
For all indicators resulting from the household survey, computation was made as population based estimates, taking into account the study design. The most relevant indicators are commented upon. For some indicators only quantitative information is provided in table format, which is self- explanatory.
3.7.1 Outcome indicators The five following outcome indicators are reported: adolescent fertility rate, contraceptive prevalence, unmet need for Family Planning, percentage of pregnant females and condom use.
3.7.1.1 Fertility rate among the young 10-24 years Definition: - Numerator- young women 10-24 who delivered in the last 12 months - Denominator- all young women 10-24
The rate is expressed for 1000 fertile women.
Of the total 757 girls/women interviewed in the household survey, “94” had a child less than one year old (table 52)
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Table 52. Fertility rate among female 10-24 years by age and survey
Age 10-14 15-19 20-24 Total Survey 2 All female 326 251 180 757 Delivered past year 2 37 55 94
Survey 2 (2016), fertility rate per 1000 6.1 147.4 305.6 124.2 Survey 1 (2014), fertility rate per 1000 4.3 98.3 237.7 97.7 Fertility rate per 1000 rural SLDHS 2013 NA 155 257 NA
There is an apparent increase in fertility between survey 1 and survey 2. It is important however to mitigate this observation for various reasons: (i) numbers are too low for adequate power, (ii) the survey 1 sample was small, iii) some girls in the age group 10-14 are not yet fertile (iv) the present data are very similar to the 2013 SLDHS, (v) UNFPA interventions are unlikely to have an effect on fertility after less than two years and during the EVD outbreak. No further analyses on this indicator have been performed.
3.7.1.2 Contraceptive prevalence rate: % women of reproductive age currently using modern contraceptive methods Definition:
Numerator - women who are married or in union currently using, or whose sexual partner is currently using, at least one method of contraception Denominator - women who are married or in a union (n= 236). The prevalence is expressed as a percentage.
There is some controversy concerning “lactational amenorrhea” and “rhythm method”, as to whether these are “modern methods”. We excluded them, as we did as well in survey 132. There were 236 women married or in union; of these, 70 used at least one modern method, giving a prevalence of 30.1% for a modern method. If non modern methods are included the total is 90, giving a prevalence of 37.3% any method.
This indicator was available through two sets of questions and the data were consistent. Data are presented by age (table 53). The difference between the two surveys has been computed; there is a trend for both males and females, but the results are not significant (table 54).
Table 53. Contraceptive prevalence of modern methods if in a union or married, by age and sex, survey 2 Contraceptive Male Female Total prevalence for modern methods % 95% CI % 95% CI % 95% CI 10-14 6.5 0.3;62.4 55.2 8.4;94.3 43.4 13.0;79.7 15-19 65.6 23.8;92.1 24.5 15.4;36.8 30.2 19.6;43.4 20-24 33.9 15.4;59.1 36.5 22.4;53.4 36.1 22.5;52.3 10-24 43.4 23.3;66.0 32.2 21.9;44.6 34.0 21.7;46.2
32 Modern methods included in the survey : male and female condoms, male and female sterilization, contraceptive pills, IUD, implants, injectables and emergency contraception
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Table 54. Difference in population estimates of contraceptive prevalence of modern methods among those in a union or married, by sex and survey Age adjusted Contraceptive prevalence Difference Survey 1 Survey 2 difference of modern methods (95% CI) (95% CI) Male 40.7 43.4 2.7 (-24.9; 30.3) 0.7 (-26.2; 27.6) Female 24.6 32.2 7.6 (-7.1; 22.4) 7.7 (-7.2; 22.5) All 28.9 34 5.1 (-10.9; 21.1) 5.0 (-10.6; 20.7)
3.7.1.3 Unmet need for Family Planning among the 10-24 years old girls/women Definition used in this survey:
Numerator - women married or in union who are not using modern Family Planning, who are not pregnant and who are not trying to get pregnant Denominator - all women married or in union (n=236)
There has been a revised definition of “unmet need” in 2012. In the revised definition contraceptive calendars are no longer in use and the unmet need category has been broadened to include all pregnant and postpartum amenorrheic women with an unwanted pregnancy (i.e. regardless of contraceptive behaviour at the time)33. This last condition has not been included in our survey to ensure consistency with survey 1. This implies that union or marriage is no more a condition for “unmet need”.
The reasons for not using modern Family Planning are described in §3.2.1.3.
Unmet need has been computed for women in union (table 55). It was also estimated for the entire population of sexually active, both married/in union and unmarried/not in union estimated for the entire population (table 56).
In both these tables results are presented by sex and age group.
Table 55. Unmet need for FP among female in a union, by survey and by age for survey 2 Unmet need in females (10-24) in a union % 95% CI Women in a union 2016, all age categories 31.4 23.1;41.0 Women in a union 2014, all age categories 23.4 15.0;34.6 Unmet need in females in a union by age. 2016 % 95% CI 10-14 27.9 3.4;81.1 15-19 43.1 24.5;64.0 20-24 23.0 15.1;33.5 10-24 31.4 23.1;41.0
33 Bradley SE., Croft TN, Fishel JD, Westoff CF. Revising unmet need for Family Planning- DHS Analytical Studies 25. ICF Int Calverton Md USA. 2012:1-75
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Table 56. Unmet need for FP among female 10-24 who are sexually active, by survey and by age for survey 2 Unmet need in females (10-24)
sexually active % 95% CI Women sexually active 2016, all age categories 23.9 , Women sexually active 2014, all age categories 27.7 20.2;36.7 Unmet need in females sexually active, 2016 % 95% CI 10-14 39.6 16.6;68.2 15-19 29.0 16.0;46.7 20-24 16.2 5.1;41.2 10-24 23.9 12.8;40.0
As for the contraceptive prevalence, the difference has also been computed (table 57)
Table 57. Difference 2014 -2016: unmet need for Family Planning for female in union or married, Age adjusted Unmet need for Family Difference Survey 1 Survey 2 difference Planning (95% CI) (95% CI) Female in a union 23.4 31.4 8.0 (-2.4 ; 18.3) 7.4 (-2.7 ; 17.4) Female sexually active 27.5 23.9 -3.6 (-18.4 ; 11.2) -4.8 (-19.8 ; 10.2)
Again, there is no significant change.
3.7.1.4 Percentage of pregnant females by age category Definition used in this survey:
Numerator - girls who said they were pregnant Denominator - all women who already had sex34
This indicator showed a statistically significant difference for the 10-24 age group. A smaller proportion of girls were pregnant during the second survey. However, above mentioned results showed that fertility rate slightly increased. These results must therefore be taken with precaution.
Table 58. Difference between survey 1 and survey 2: female pregnancy rate, by age group Difference Age adjusted Proportion of pregnant girls Survey 1 Survey 2 (95% CI) difference (95% CI) 10-19 12.1 9.4 -2.7 (-8.2 ; 2.8) -2.2 (-7.3 ; 2.8) 10-24 14.4 8.4 -6.0 (-9.6; -2.4) -6.3 (-9.3 ; -3.2)
3.7.1.5 Condom use Definition: - Numerator - used condom yes (last time or each time last year) - Denominator - those people who responded yes to having had sex in the past year
34 The same denominator was used in survey 1. There is an error in the survey 1 report in the description of the denominator for this indicator.
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Condom use was assessed in terms of type of use (last sex (n= 91) by age, by “in or out of school”, and by literacy. Among these, those who reported “use every time in the past year” (n=62), were assessed by age and by literacy. It is important to acknowledge that the denominators are small, which gives very little statistical power to the data. Nevertheless, all data are presented by sex and by total population which is then compared with the results from survey 1 (table 59).
Condom use at last sex
Table 59. Condom use at last sex, by sex and age, comparison with survey 1 Total Total Survey 1 Male survey 2 Female survey 2 Condom use at last sex survey 2 % 95% CI % 95% CI % 95% CI % 95% CI 10-14 yrs 20.8 2.3;74.3 23.2 9.7;45.9 22.4 7.0;52.9 12.7 0;27.4 15-19 yrs 25.8 12.9;45.0 7.8 3.4;16.9 13.1 6.8;23.7 11.7 6.1;17.4 20-24 yrs 44.6 34.9;54.7 9.2 1.9;33.9 21.1 8.3;43.9 13.5 11.1;15.9 10-24 yrs 35.1 24.7;47.2 9.3 4.1;19.7 17.5 9.2;30.6 12.6 9.7;15.6
Interpretation of age differences is complex, because there can be valid reasons for not using condoms at different ages, such as a stable relationship or desire for children. On the other hand, data from the literature repeatedly show the importance of education as a determinant. This was approached both through “in or out of school” and through “literacy yes/no” (tables 61 and 62).
The indicator on condom use at last sex by sex, showed a statistically significant difference for males when adjusted for age (table 60)
Table 60. Difference between survey 1 and survey 2: condom use at last sex by sex
Condom used at last sex Survey 1 Survey 2 Age adjusted Difference % % difference (95% CI) (95% CI) Male 24.3 35.1 10.8 (-1.1 ; 22.7) 11.5 (0.1 ; 23.0) Female 5.0 9.3 4.3 (-0.3 ; 11.2) 4.2 (-0.3 ; 10.9) All 12.6 17.5 4.9 (-5.1 ; 15.0) 5.0 (-5.4 ; 15.4)
Table 61. Condom use at last sex, by sex,” in/out of school” 2016 and 2014, population estimates Condom use at last Males Females Total Survey 1 All Survey 2 sex % 95% CI % 95% CI % 95% CI % 95% CI In training 35.2 15.2;62.2 13.2 6.8;24.3 22.4 11.0;40.3 15.9 10.9;21.5 Not in training 34.9 14.3;63.3 6.1 2.2;16.0 12.0 7.3;18.9 8.7 3.6;13.9 All 35.1 24.7;47.2 9.3 4.1;19.7 17.5 9.2;30.6 12.6 9.7;15.6
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We also looked at literacy as a determinant of condom use.
Table 62. Condom use at last sexual intercourse, by sex and literacy, comparison with survey 1 Condom use at last sexual Male survey 2 Female survey 2 All survey 2 All survey 1 intercourse 95% % 95% CI % 95% CI % % 95% CI CI Cannot read 7.3 0.4;60.8 3.4 1.4;8.0 4.1 1.4;11.5 4.9 2.9;6.9 Can read 42.2 24.8;61.7 13.6 5.7;29.2 24.6 11.8;44.3 19.1 14.4;23.7 Total 35.1 24.7;47.2 9.3 4.1;19.7 17.5 9.2;30.6 12.6 9.7;15.6 In summary, the negative effect of poor education has not been changed. On the other hand, for people who can read there is a trend towards better use of condoms. This trend however was not statistically significant (table 63)
Table 63. Difference between survey 1 and survey 2: condom use at last sexual intercourse by literacy
Condom used at last sex Survey 1 Survey 2 Difference Age adjusted difference % % (95% CI) (95% CI) Can read 18.7 24.6 5.9 (-9.8 ; 21.6) 6.1 (-10.3 ; 22.6) Cannot read 4.9 4.1 -0.8 (-5.3 ; 3.6) -1.4 (-6.2 ; 3.3) All 12.6 17.5 4.9 (-5.1 ; 15.0) 5.0 (-5.4 ; 15.4)
Consistent condom use Finally, consistent condom use was addressed.
Table 64 Consistent condom use as a % of users at last sex by sex and age, Survey 2 and survey 1, population estimates Male survey 2 Female survey 2 All survey 2 All survey 1 Consistent condom use % 95% CI % 95% CI % 95% CI % 95% CI 10-14 yrs 100 / 100 / 100.0 / 100 NA 15-19 yrs 73.6 54.2-86.8 74.0 53.4-87.5 73.8 56.5-85.9 52.5 52.5 20-24 yrs 63.0 26.3-89.0 78.0 17.2-98.4 67.5 25.1-92.8 59.7 59.7 Total 10-24 yrs 67.9 43.3-85.4 79.6 53.5-93.0 72.3 48.4-87.9 58.7 58.7
Again we explored the relation to literacy.
Table 65. Consistent condom use, as a % of users at last sexual intercourse, by sex and literacy, Survey 2 and survey 1, population estimates Male survey 2 Female survey 2 All survey 2 All survey 1 Consistent condom use
% 95% CI % 95% CI % 95% CI % 95% CI
Cannot read 67.4 51.7;80.0 87.0 54.0;97.4 80.6 57.4;92.7 52.3 24.9;79.8 Can read 67.9 42.3;85.9 78.3 46.6;93.7 71.5 45.5;88.3 60.4 45.6;75.1 All 67.9 43.3;85.4 79.6 53.5;93.0 72.3 48.4;87.9 58.7 47.3;70.1 There was no significant change between 2014 and 2016
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We also explored exposure to VPE and use of condom at last sexual intercourse.
Table 66. Condom use according to having met a VPE, by age groups and survey
Use of condom Survey 1 Survey 2
Difference Age adjusted difference % % (95% CI) (95% CI) Used condom at last sexual intercourse according to meet VPE, all age categories meet VPE 20.7 17.8 -2.9 (-18.7;12.8) -2.8 (-18.8; 13.2) no meet VPE 9.2 17.3 8.1 (0.4; 15.9) 8.2 (0.9 ;16.3) Total (10-24) 12.5 17.4 4.9 ( -5.1; 15.0) 5.0 (-5.3; 15.4) Used condom at last sexual intercourse according to meet VPE, young 10-19 yrs meet VPE 22 12.9 -9.1 (-21.5 ; 3.3) -9.1 (-21.7; 3.6) no meet VPE 6.6 15.5 8.9 (-0.1; 17.9) 8.3 (0.7 ;17.4) Total (10 -19) 11.7 14.2 2.5 ( -5.6; 10.5) 2.3 (-5.7; 10.3)
There was no statistically significant change between survey 1 and survey 2.
3.7.2 Output 1 indicators – demand creation This section presents the estimation of indicators related to this output. It includes the agreed indicators and others found relevant.
3.7.2.1 Volunteers peer educators We explored exposure to VPEs by sex in the household survey. As already mentioned. the exposure to VPE increased between survey 1 and survey 2. This increase is even statistically significant at the population level for males.
Table 67. Meeting a VPE in the past year, by sex and survey % young 10-24 reporting meeting a Survey 1 Survey 2 Difference Age adjusted VPE in the past year % % (95% CI) difference (95% CI) Male 28.0 53.5 25.5 (6.0 ; 44.9) 26.2 (6.6 ; 45.9) Female 25.7 44.3 18.6 (-9.3 ; 46.5) 18.6 (-9.1 ; 46.3) All 26.7 48 21.3 (-2.5 ; 45.2) 21.6 (-2.2 ; 45.3)
We also explored exposure to VPE influencing to attend a health facility by sex.
Table 68. Young reporting VPE influencing them to attend a health facility in the past year, by sex and survey
% young 10 -24 years reporting VPE Age adjusted Survey 1 Survey 2 Difference influencing them to attend a health difference % % (95% CI) facility in the past year (95% CI)
Male 53.7 71.1 17.4 (-13.6 ;48.4) 18.6 (-8.2;45.5) Female 42.8 64.1 21.2 (-24.0; 66.4) 21.1 (-21.1; 63.4) All 47.1 66.6 19.5 (-19.7; 58.8) 20.2 (-15.4; 55.8) In survey 2, more young both male and female mentioned that VPE influenced them to go to a health facility, however this change is not statistically significant.
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We also explored VPE exposure among Family Planning clients in the health facility survey.
Table 69. Percentage Family Planning clients reporting interaction with VPE Survey 1 Survey 2 P-value* N n % 95% CI N n % 95% CI Percentage of FP clients reporting 212 52 24.5 12.8% ; 36.2% 211 65 30.8 24.6;37.0 0.093 meeting a VPE last year Percentage of FP clients who reported the VPE interaction having influence them to visit the health facility today 52 46 88.5 79.1% ; 97.9% 65 50 76.9 66.7;87.1 0.957 for family planning services (among those that have met a VPE) *Chi-squared Test
Among Family Planning clients, there has been and increased in exposure to VPEs (20% increase) between survey 1 and survey 2, however this difference is not statistically significant.
3.7.2.2 Health facilities interacting with CAGs The interactions between health facilities and CAGs was explored (table 62).
Table 70. Percentage of health facilities being linked to a CAG and percentage of health facilities keeping records of CAGs referrals Survey 1 Survey 2 P-value* P-value** N n % 95% CI N n % 95% CI Percentage of surveyed health 107 78 73.8 65.5% ; 82.1% 109 93 85.3 78.7% ; 92.0% 0.049 >1 facilities being linked to a CAG Percentage of surveyed health facilities keeping records of CAGs 78 58 74.4 64.7 ;84.1 93 48 51.6 41.4% ; 61.8% 0.009 >1 referral, among those being linked to a CAG *Chi-squared Test ** McNemar test. Only for the audit interview data, as the studies have been conducted in two time period in same health facility35
In the country, the CAGs are thinly spread across the chiefdoms. The number of CAGs per chiefdom is not reflective of the number of health facilities in a particular chiefdom. Some health facilities do not have CAGs within their catchment area. There has been an improvement in the proportion of health facilities linked to CAGS compared with survey 1 (13% increase). This is not the case for health facilities keeping records of CAGs referrals. In none of these two cases the differences were statistically significant.
3.7.2.3 Community wellness advocacy groups We explored the exposure to CAGs among young 10-24 years interviewed in the household survey.
We first explored the exposure to CAGs (having met a CAG) in the past year by young aged 10-24 years.
35 In statistics, McNemar's test is a statistical test used on paired nominal data. It is applied to 2 × 2 contingency tables with a dichotomous trait, with matched pairs of subjects, to determine whether the row and column marginal frequencies are equal (that is, whether there is "marginal homogeneity").
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Table 71. Difference between survey 1 and survey 2: young (10 -24) meeting a CAG in the past year, by sex Age adjusted % young 10-24 meeting a CAG in the past Survey 1 Survey 2 Difference difference year % % (95 % CI) (95% CI) Male 10.5 14.7 4.2 (-4.5 ; 12.9) 5.2 (3.7 ;14.1) Female 17.3 29.2 11.9 (4.1 ; 19.6) 12.4 (5.5 ; 19.3) All 14.3 23.3 9.0 (1.5 ; 16.5) 10.0 (2.6 ; 17.4)
In survey 2, 4.2% more male and 11.9% more female reported having met CAG compared to survey 1. This increase is statistically significant for both sexes. However, among the young who met a CAG, a lower proportion was referred to a health facility or influenced to go to a health facility. This decrease is significant in female and for all young 10 -24 (table 72).
Table 72. Difference between survey 1 and survey 2: CAG influences to go to the health facility, by sex
% of young aged 10-24 reporting Difference Difference CAG influencing them to attend a Survey 1 Survey 2 adjusted by age (95% IC) health facility in the past year (95% CI)
Male 22.1 14.9 -7.2 (-36.2 ; 21.7) -7.4 (-35.8 ; 21.0) Female 29.5 6.7 -22.8 (-39.8; -59.1) -22.7 (-39.7; -5.8) All 27.4 8.4 -19.8 (-33.0 ; -6.6) -19.8 (-33.1 ; -6.5)
The denominator includes young 10-24 years who have met a CAG and went to the health facility in the past year. The same indicator was disaggregated by age, only for female.
Table 73. CAG referral to go to the health facility, females by age category
% of female being referred by Female Survey 2 Female Survey 1 a CAG to a health facility in
the past year % 95% CI % 95% CI 10-14 yrs 0 / 12.1 6.1;18.2 15-19 yrs 4.7 1.4;15.0 15.1 2.6;27.2 20-24 yrs 9.7 2.2;33.5 16.9 8.8;24.9 10-24 yrs 6.7 2.0;20.0 16.5 7.9;25.1
The number of respondents are small, therefore the results should be interpreted with caution. This is probably an indication that programme activities may need to be revised to ensure greater coverage and reach out to young people by CAG.
Additionally, we explored CAGs referrals among Family Planning clients interviewed in the health facility survey.
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Table 74. Family Planning clients referred by a CAGs
Survey 1 Survey 2 P-value* N n % 95% CI N n % 95% CI Percentage family planning clients 211 81 38.4 27.8%; 49% 211 135 64.0 57.5 ; 70.5 <0.001 reporting meeting a CAG
Percentage family planning clients reporting referred by a CAG in the 81 35 43.2 26.8%;59.6% 135 86 63.7 55.6 ; 71.9 0.003 past year, among those that have met a CAG Percentage of family planning clients who mention interaction 51 37 72.5 60.2% ; 84.8% 135 122 90.3 85.3 ; 95.3 <0.001 with CAG may influencing them to attend a health facility in the past *Chi-squared Test
The situation has improved for the three indicators compared with survey 1. There has been a 40% increase in Family Planning clients reporting meeting a CAG, ii) 32% increase in Family Planning clients reporting being referred by a CAG in the past year (among those who have met a CAG) and iii) 20% increase in interaction with CAG influencing them to attend a health facility.
As in survey 1, there was interest to know more about the under 19 years old age group. The percentage of female clients under 19 years who visited a health facility last year and who reported that they were referred by the CAG (table 68). This indicator was calculated only for the Family Planning clients who reported having met a CAG. There were only few Family Planning clients under 19 years of age who reported having met a CAG. Therefore, the results should be interpreted with caution due to small sample size.
Table 75. Percentage of female Family Planning clients under 19 years who visited a health facility and reported that they were referred by the CAG in the past year, survey 1 and survey 2 P- Survey 1 Survey 2 value* N n % 95% CI N n % 95% CI Percentage of females Family Planning clients under 19 year of age who visited a health facility who reported 9 3 33.3 2.5% ; 64.1% 19 11 57.9 33.4 ; 82.3 0.225 that they were referred by the CAG in the past year, among those having met a CAG *Chi-squared test
The interaction with CAGs influencing Family Planning clients to attend a health facility today for Family Planning services was also explored (table 76).
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Table 76. Percentage of Family Planning clients who mentioned interaction with a CAG influencing them to attend a health facility today, survey 2 Survey 2 n % 95% CI Percentage of Family Planning clients who reported CAG influencing them to attend a health facility for FP services today. among 106 79.1 72.2 ; 86.0 those reporting having met a CAG （n=134)
The referral by CAGs of girls 10 -19 years to a health facility was explored as well in the household survey (table 77).
Table 77. Percentage of girls 10 -19 years referred by CAGs to the health facility, survey 2 Survey 2, indicators n % 95% CI Percentage of girls 10 – 19 yrs who were referred to the health facility by a CAG in the past year (denominator includes all girls under 19, whether they have met a 0;2.6 8 1.0* CAG or not)
Percentage of girls 10 – 19 yrs who were referred to the health facility by a CAG in the past year (denominator includes all girls who have met a CAG and who answered the question about being referred) 8 4.6* 0;10.2
Percentage of girls 10 – 19 yrs who visited a public health facility who reported that they were referred by a CAG in the past year (denominator includes all girls who have met a CAG and who reported having visited the health facility in the past 4 3.7* 0;7.9 year)) Percentage of girls 10 – 19 yrs who visited a public health facility who reported that they were referred by a CAG in the past year (denominator includes all girls who 4 1.5 have went to the health facility in the past year, whether they have met a CAG or 0;3.2 not) *survey design
3.7.2.4 Knowledge of modern Family Planning methods The proportion of girls who has heard of more than one modern Family Planning method was explored. Two third of male and three quarter of female have heard of at least one modern method of contraception. Most young know between 3 and 6 methods
Table 78. Having heard of modern Family Planning method, by the number of methods and sex Ever heard of a modern Males (n=652) Females (n=757) Total Family Planning method, survey 2 % 95% CI % 95% CI % 95% CI Heard of no method 36 29.5;43.5 24.0 16.7;33.3 29.0 24.9;33.6 Heard of at least one method 63.8 56.5;70.5 76.0 66.7;83.3 71.0 66.4;75.1 Disaggregated by number of
method Ever heard of 1 modern 7.3 5.8;9.1 4.8 3.5;6.7 5.8 4.7;7.2 method
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Ever heard of 2 modern 4.8 2.9;7.8 3.8 2.2;6.5 4.2 2.6;6.8 methods Ever heard of 3 modern 7.1 5.0;10.1 7.4 5.8;9.6 7.3 5.8;9.1 methods Ever heard of 4 modern 16 13.2;19.3 19.3 15.6;23.6 17.9 15.9;20.2 methods Ever heard of 5 modern 9 5.7;16.0 11.3 9.1;14.0 10.6 8.7;12.9 methods Ever heard of 6 modern 5.8 3.2;10.3 10.3 8.2;12.9 8.5 6.9;10.4 methods Ever heard of 7 modern 5.9 4.5;7.8 5.3 2.6;10.5 5.6 3.9;7.9 methods Ever heard of 8 modern 4 2.9;7.2 6.0 4.5;8.0 5.4 4.1;7.1 methods Ever heard of 9 modern 2.6 1.3;5.4 7.7 3.2;17.2 5.6 3.1;10.0 methods
Table 79. Difference survey 1 and survey 2:Young people who have heard of at least one modern Family Planning method, by sex % of young people aged 10-24 yrs Age adjusted who have heard of at least one Survey 1 Survey 2 Difference difference modern Family Planning method % % (95% IC) (95% CI)
Male 68.1 63.8 -4.3 (-14.9 ; 6.2) 1.0 (-13.0 ; 15.1) Female 69.2 76.0 6.8 (-8.6 ; 22.2) 8.2 (-5.8 ; 22.2) All 68.7 71.0 2.3 (-9.4 ; 13.9) 5.2 (-8.5 ; 18.9)
Between survey 1 and survey 2, the proportion of young who have heard of at least one modern Family Planning method stayed unchanged. There is a slight increase in female but this is not significant.
3.7.2.5 Source of information for sexual and reproductive health among young people 10-24 years For interviewees in the household survey, health structures, friends and schools were cited as their most common source of information on sexual and reproductive health matters. This is similar to survey 1. Table 80. Source of information for SRH Source of information for SRH, survey 2 % 95% CI School (n=1409) 38.8 30.5;47.9 Parents (n=1409) 14.8 11.6;18.8 Friends (n=1409) 32.5 27.5;37.9 Health structures (n=1409) 25.7 17.3;36.4 Community health workers (n=1409) 19.7 9.0;37.9
Internet (n=1409) 0.8 0.3;1.9 Volunteer Peer Educator (n=1409) 19.0 12.1;28.6
Community Wellness Advocates (n=1409) 5.1 3.6;7.3
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I don’t need this information (n=1409) 10.6 4.3;24.2 I don’t know (1409) 16.4 10.1;25.6 Other source of information cited N° of citation Other family members (old brother or sister) 4 Radio 36 Marie Stopes 5
3.7.3 Output 2 indicators - increased availability
3.7.3.1 Uptake of modern methods by the young people (among Family Planning clients) The percentage of young (10-24 years) new acceptors of contraceptives disaggregated by method was calculated for the Family Planning clients who were interviewed at the health facility. Only 47 subjects answered this question including 18 less than 25 years of age. Their method of choice included only four methods: pill, injectable, implants and condoms. Three clients selected pill, six clients selected injectable, five clients selected implant.
Table 81. Percentage of new acceptors of contraceptive methods, among Family Planning clients interviewed (10-24 years of age) by method accepted, survey 2
Proportion of new acceptors of All age (n=211) Aged 12-24 years (n=90) contraceptive methods, Yes Yes disaggregated by method n % n % Acceptors new to contraception 62 29.4 29 32.2 Distribution by contraceptives 47 18 method Pill 21 44.7 7 38.9 Injectable 17 36.2 6 33.3 Implant (Captain Band) 8 17.0 5 27.8 Condom 1 2.1 0 0 Note: Some new acceptors mentioned two contraceptive methods
3.7.3.2 Availability of IUDs and implants at the health facilities visited Table 82 presents the availability of long acting Family Planning methods (IUD and implants) on the day of the health facility visit.
Table 82. Percentage of surveyed SDP with long acting Family Planning methods available on the day of the visit, survey 2 % of (visited) SDP with long acting Family Planning methods YES available today available (IUD and implants). Survey 2. YES. availability of Long term methods on the day of the visit n % All health facilities IUD (N=109) 46 42.2 Implant (N=109) 81 74.3 Hospital IUD (N=9) 5 55.6 Implant (N=9) 7 77.8 CHC IUD (N=45) 25 55.6 Implant (N=45) 40 88.9 CHP
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IUD (N=36) 10 27.8 Implant (N=36) 26 72.2 MCHP IUD (N=19) 3 15.8 Implant (N=19) 19 100.6
3.7.3.3 Youth friendly services The percentage of young people (10-24 years) considering that health services are not youth friendly was calculated from the results of the household survey (table 83).
Table 83. Percentage of young (10 -24 years) who think that the health services are not youth friendly, survey 2 % of young 10 -24 years who think Male (n=130) Female (n=258) Total that health services are not youth friendly % 95% CI % 95% CI % 95% CI 10 – 24 years 3.1 0.6;15.1 2.3 0.6;8.7 2.5 0.6;9.9
Calculated from results of the health facility survey (table 84)
Table 84. Percentage of Family Planning clients who think this facility is youth friendly, survey 2
Percentage of Family Planning clients who think this facility All ages (n=211) Aged 12-24 years (n=90) is youth friendly n % n % Very much 197 92.1 80 88.9 Much 0 0 0 0 Average 14 6.5 10 11.1
3.7.3.4 Utilisation of health services Calculated from results of the household survey (table 85)
Table 85. Difference survey 1 and survey 2: Young (10-24) who have used the health facility in the past year, by sex
% of young 10-24 who have used Age adjusted Survey 1 Survey 2 Difference the health facility in the past year difference % % (95% IC) (n denominator for survey 2) (95% CI)
Male 28.5 20.0 -8.5 (-22.7 ; 5.8) -7.3 (-22.1 ; 7.6) Female 40.6 33.7 -6.9 (-27.41 ; 3.5) -6.5 (-26.5 ; 13.6) All 35.4 28.1 -7.3 (-24.1 ; 9.6) -6.0 (-23.2 ; 11.3)
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4 DISCUSSION AND CONCLUSION
4.1 Statement of principal findings
The main finding is that the surveys and the focus group results are a testimony to the resilience of the Sierra Leones people. It had been expected that the EVD outbreak would constitute a terrible set- back to the IRMNH programme, especially as this was the message of recently published studies and reports (see §1.5). As an example, a Norwegian team36 reported that both in-hospital deliveries and C-sections substantially declined shortly after the onset of the EVD outbreak, which, according to their expectations, will significantly increase maternal and perinatal deaths.
In general, in this second set of IRMNH Sierra Leone surveys there has been no dramatic deterioration as compared to the first set. The results confirm the findings of the latest DHS and our IRMNH survey 1 (conducted in 2014) in relation to the present situation in Sierra Leone, both in general and for SRH. Sierra Leone is a country where the population lives with major needs, and where access to basic commodities remains a serious issue. This results in maintaining its very low rank (181th position out of 188 countries) on the UN Human Development Index classification37, and explains why Sierra Leone is one of the 10 countries with “stream one” funding from UNFPA38.
4.1.1 Outcome indicators Between survey 1 and survey 2, we found two significant changes, both in the desirable direction: fewer girls were pregnant, and more boys used condom at their last sexual intercourse.
As in 2014, one of the most marking features of the household survey is that it includes the age group 10 to 14 years old, a group that is not usually surveyed. This is a fragile group: 8% of the girls declared they were sexually active and 1.2% had already given birth. Only 40% have heard of more than one modern method. Also, in this same age group, less than half can read a simple sentence (in part or fully).
Adolescent and child fertility rate The adolescent fertility rate (given birth in the year prior to the survey) was 147.4‰ (98.3‰ in survey 1) in the age-group 15-19. The child fertility rate (age group 10- 14 years) was 6.2‰ (4.3‰ in survey 1). Although, these changes were not statistically significant.
Contraceptive prevalence and unmet need There was a trend in the desirable direction for use of modern Family Planning methods: 43.4% of boys and 32.2% of girls in survey 2, against 40.7% of boys and 24.6% of girls in survey 1 used modern Family Planning method. The increase however did not reach statistical significance.
In a similar way, unmet need decreased from 27.7% in survey 1 to 23.9% in survey 2 among sexually active girls/women.
36 Brolin Ribacke KJ, van Duinen AJ, Nordenstedt H, Höijer J, Molnes R, Froseth TW, Koroma AP, Darj E, Bolkan HA, Ekström A. The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone. PLoS One. 2016 Feb 24;11(2):e0150080 37 UNDP annual report http://hdr.undp.org/fr/content/human-development-report-2013-summary 38 UNFPA. The Global Programme to Enhance Reproductive Health Commodity Security report 2012 http://www.unfpa.org/webdav/site/global/shared/documents/publications/2013/UNFPA%20GPRHCS%20Annual%20Repor t%202012_web%20final.pdf
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Proportion pregnant adolescents The pregnancy rate decreased significantly from 14.4% in survey 1 to 8.4% in survey 2 for female 10- 24 yrs (difference [95% CI] adjusted for age – 6.3 [-9.3 to -3.2]).
4.1.2 Output 1 (demand creation) indicators
Condom use Generally the trend was towards increased use of condom in all contexts. It reached statistical significance for condom use at last sex boys all ages, increasing from 24.34% to 35.1% (difference [CI] adjusted on age + 11.5 [0.1 – 23.3].
UNFPA supported interventions: Saliwansai, VPEs, enhanced CAGs Saliwansai was not on air anymore. For the VPEs, exposure almost doubled without reaching statistical significance for male only. The difference in exposure between VPE+ and VPE- areas is no longer noticeable (see for more information in the next section). In general, there was an increase in topics that had been discussed with VPEs, especially staying on at school and not marrying too early. CAG exposure also increased, reaching statistical significance for both sexes when adjusted for age.
4.1.3 Output 2 (increased availability) indicators
As in survey 1, Family Planning services are being offered and contraceptives methods are available at all type of health facilities. The proportion of health facilities offering six or more contraceptive methods increased when compared with survey 1 (58% in survey 2, 50% in survey 1). The frequency of non-stock-outs of contraceptive commodities at the health facilities in the last three months previous to the survey has improved in comparison to survey 1. In survey 2, for each of 6/11 contraceptive commodities inquired, there was a larger number of health facilities reporting not having stock outs in the last three months when compared to survey 1.
As in in survey 1, the mix of FP services and available commodities varied with the type of health facility. All health facilities were offering the male condoms; the majority of health facilities were offering the combined oral contraceptive pills and the combined injectable contraceptives. The availability of long term contraceptive methods on the day of the visit was less generalised. IUDs and implants were available respectively in 46% (67% in survey 1) and in 74% (79% in survey 1) of the health facilities surveyed. In correspondence with national policies a good proportion of hospitals had these commodities available. However, the availability of implants and IUD on the day of the visits at hospitals and CHC presents a downward trend. In the hospitals visited 78% had implants and 56% had IUDs on the day of the visit (100% and 71% respectively in survey 1). At CHCs, 89% had implants and 56% had IUDs (85% and 76% respectively in survey 1). On the other hand, it is encouraging to find that implant services are being made available in remote rural areas where CHPs and MCHPs can be located39.
It was assumed that the EVD outbreak might have an effect of decreasing access to Family Planning services, which was indeed the case mainly for access to Family Planning services at hospitals, 90% of health facilities reported that they offered Family Planning services during the EVD outbreak (67% of hospitals, 91% of CHC, 91% of CHP and 95% of MCHP). The utilisation of Family Planning methods might have also been affected. Among those family clients responding to the question “did you for any reason stop taking FP methods during the EVD outbreak?”, 24% responded affirmatively.
39 The reader is referred to Annex 1, list of surveyed health facilities. The type of health facilities correspond to the classification made for survey 1. It could be that some of these health facilities have been recategorised.
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The survey results confirm the results of survey 1 and indicate that important gaps remain in training of providers on long term methods. Particularly, in the training of the cadres that are most likely to be assigned to the provision of Family Planning services such as maternal and child health aides (MCH aide) and state registered nurses. In both, survey 2 and survey 1, 83% of health facilities had at least one MCH aide assigned to provide Family Planning services. However only 9% (30% in survey 1) of health facilities had at least one MCH aide trained on long term methods. Issues related to human resources for Family Planning should be looked at within the overall framework of availability of human resources in the country.
As in survey 1, and despite the EVD outbreak, the survey identified strong aspects of quality care Family Planning services being provided at the health facilities. Both surveys show that for 90% or more of the Family Planning encounters, the clients were treated with respect. In survey 2 confidentiality was ensured in 74% of encounters (95% in survey 1). Both surveys show that new Family Planning clients in almost all cases were provided information on how to use the methods. their side effects of the methods and what to do in case of problems. The Family Planning clients had a positive perception of the services received. In both surveys, more than 90% of clients felt comfortable asking questions and thought that the amount of information provided to them was good or very good.
The survey 1 also identified a few areas of quality of care that should be improved. One these aspects was hand washing before the application of an injectable, as component of “compliance with infection procedures”. Hand washing was not done in 15% (one third in survey 1) of the cases observed. This aspect has improved, which may be related to enhanced hand washing recommendation related to the EBV outbreak.
Another aspect requiring improvement was the availability of basic equipment and related items for the provision of IUDs and implants. The availability of three items necessary for implant insertion (implant kits, sterile gloves, and xylocaine/lidocaine) has not improved. These three items were available in 42% (55% in survey 1) of health facilities. The situation has improved for items required for insertion of IUDs; 55% (3.6% in survey 1) of health facilities had the five items for insertions of IUDs (specula, tenaculum, scissors, flashlight, standing lamp).
The storing conditions for contraceptive pills and condoms appears to have been improved in comparison with survey 1. However the storing conditions for IUDs and implant are similar to the findings of survey 1.
Not all health facilities scored equally on all aspects of quality of care inquired, which indicates that improvement efforts should be facility-specific. However, all those involved in provision of Family Planning services should be aware that there is always scope to improve the quality of care.
Youth friendly services This aspect was explored as a planned component of the UNFPA package, however, it was accepted that developing youth friendly services might not be a priority when many of the country’s resources were target to fight the EVD.
Approximately one third, 30% (10% in 2014) of the health facilities surveyed were found to comply with the three defined criteria for “being upgraded to provide youth friendly services”. The three criteria cover issues of human resources, infrastructure and availability of information and educational material. There have been improvements in all these criteria, with gaps remaining in training of human resources and infrastructure conditions. The health facilities were most likely to have IEC materials on Family Planning for adolescents and youth in 99% (93% in survey 1) of health
hera - ULB - FOCUS 1000 / Final Report Survey 2 / July 2016 74 Survey 2 / Multi-Year Annual Survey to Monitor Programme Effectiveness of the Improving Reproductive Maternal and Newborn Health (IRMNH) Programme- Sierra Leone facilities. 52% (23% in survey 1) of the health facilities surveyed are providing services to the young in a consultation room that offers privacy. 45% (one third in survey 140) had at least one staff trained in youth friendly services. However, important gaps remain in availability of trained staff in youth friendly services. For example, only 34% of health facilities had at least one maternal and child health aides trained in provision of youth friendly services.
The linkages between CAGs and health facilities There has been a 13% increase (85% in survey 2. 74% in survey 1) in linkages between health facilities and CAGS. The situation however has deteriorated with regards to record keeping of CAGs referrals. Among those health facilities linked to CAGs, 52% (65% in survey 1) reported keeping records of CAGs referrals.
4.2 Strengths and weaknesses of the study
The first strength that needs to be reported is that the surveys and the focus groups were performed as soon as was authorized after the EVD outbreak, even despite the fact that the outbreak was not totally finished. In fact, in Guinea and Liberia. There have still been cases reported in March and April 201641 .
As in survey 1, the present set of surveys is methodologically strong, with six data collection instruments, which focus on four specific aspects:
i) special needs and demands of the young population 10-24 years, including the 10-14 years group (individual survey), and their context (head of household survey); ii) expressed and perceived KAP and demands of interviewees (focus groups); iii) situation at the health facility (interview of health facility manager, client exit interview, observation of client-provider Family Planning encounter); and iv) relation between UNFPA activities and outcome / output indicators (all instruments). For the aspects (i) to (iii), the results of this survey can be compared to SLDHS 2013. The results are very much in keeping with this larger survey, confirming that the results of this IRMNH are reliable.
For the household survey, at planning stage, some methodological weaknesses were accepted at the planning stage, in particular the issue of insufficient statistical power. This was a compromise. considering that it was important to UNFPA to get information also from the 10 to 14 age group, even if most of them are not sexually active.
In the first survey, the division into four UNFPA intervention areas was effective, in particular for VPEs with exposure 4 times more likely in VPE+ areas than in VPE- areas. In this second survey, the contrast has disappeared. At this point, it remains unclear whether this is a methodological weakness (interpretation is more difficult), or a satisfactory outcome (more people are being exposed).
For the health facility survey, only a small number of individuals were available, and the interviewers had to spend much time travelling. However, this strategy opted allows to get a valid picture of the situation of health facilities, even in remote areas of the country.
40 This was expected, as for sampling design 30% of the selected facilities had at least one staff trained for the provision of youth friendly services. 41 WHO Ebola Situation Report 5 May 2016, http://apps.who.int/iris/bitstream/10665/205945/1/ebolasitrep_5may2016_eng.pdf?ua=1
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4.3 Comparing findings with other study results
Comparisons were limited to the relevant indicators and to one of the three following studies / documents: (i) SLDHS 2013; (ii) statistics or general statements about LMIC, supported by UN agencies or (iii) published studies in the 5 English speaking countries of West Africa (Gambia, Ghana, Liberia, Nigeria and Sierra Leone). The search was limited to 2015-16.
4.3.1 Outcome indicators
The fertility rate and the contraceptive prevalence observed in the household survey are of the same order of magnitude as those reported in the most recent UN 2012 fertility rate report42 for Sierra Leone as well as in the SLDHS 2013. However, one strength of this survey is that there are data for the 10-14 years old which is not the case in the other reports.
It is of interest also that in the SLDHS 2013 the fertility rate has not changed much over the five-year period, and that the only age groups where fertility is decreasing is 15-19 and 20-24 (fig 15).
Figure 16. Age – specific fertility rates (births per 1000 women) for Sierra Leone 2008-2013
Source: SLDHS 2013
For determinants of fertility and of contraceptive use, recent studies confirm the importance of literacy and education. Susuman et al. analysing total fertility rates in 10 sub-Saharan countries including Sierra Leone showed low female literacy to be the major determinant43. Another study in 3 countries including Nigeria addressed the typology of adolescents and concluded that young girls in union were less likely to use modern contraception, possibly because the union equated with no further education and having children. In this second IRMNH survey also, girls in union had a greater rate of unmet need (31%) than girls not in union (23%)44.
422012 UN World Fertility Report at http://www.un.org/en/development/desa/population/publications/dataset/fertility/wfr2012/MainFrame.html 43 Susuman AS, Chialepeh WN, Bado A, Lailulo Y. High infant mortality rate, high total fertility rate and very low female literacy in selected African countries. Scand J Public Health. 2016 Feb;44(1):2-5 44 Hounton S, Barros AJ, Amouzou A, Shiferaw S, Maïga A, Akinyemi A, Friedman H, Koroma D. Patterns and trends of contraceptive use among sexually active adolescents in Burkina Faso, Ethiopia, and Nigeria: evidence from cross-sectional studies. Glob Health Action. 2015 Nov 9;8:29737
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No specific new reference was found for condom use.
4.3.2 Output-1 (demand creation) indicators
The objective is to create demand by working within a rights-based approach that empowers individual choices and dignity, sharing information through behaviour change communication. The different routes for achieving this objective have not to this day been evaluated rigorously and there is a lack of evidence based recommendations. In addition, external validity of studies area is apt to be poor. There have been two declarations of scientists to reinforce and broaden research on SRH, especially in adolescents45 46. This is consistent with the update of the literature search in this report (§1.2.) that possibly it is necessary to go beyond the present interventions such as peer education or information booklets.
4.3.3 Output-2 (increased availability) indicators
The objective is to increase access with a special focus for underserved and hard-to-reach populations.
The main topic discussed here will be paying for Family Planning services, including paying for commodities. This was found in the household survey, in the health facility survey and in the focus groups. Published reports confirm that this is probably a reflect of reality. Already in the previous report we stated the study by Groen et al47 on Family Planning who confirms that many families mentioned financial constraints. New data confirm this, A study by Pieterse and Lodge reports that field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health workers and focus group discussions with primary healthcare users. In most clinics, women and children entitled to free care routinely paid for health services48. Interestingly in a study on the effect on care givers of the Free Care Health Initiative, implemented in 2010 by the Sierra Leone government, only 4% of doctors reported any revenues from user fees or any gifts from patients, with salary as the main component of income49.
4.4 Policy implications / unanswered questions and projection in the future
This second study provides information about the situation in early 2016, which can be compared to the baseline survey of 2014, taking into account that initially this was to occur in 2015 but that the EVD outbreak occurred in the meantime.
One unexpected finding was that though exposure to VPEs and CAGs has increased overall, no clear distinction of exposure is visible between the initial UNFPA intervention areas. However, this study provides interesting information to guide future strategies (for future surveys or programme related action) and some wide-ranging findings that raise more general questions.
45 Adanu R, Mbizvo MT, Baguiya A, Adam V, Ademe BW, Ankomah A, Aja GN, Ajuwon AJ, Esimai OA, Ibrahim T, Mogobe DK, Tunçalp Ö, Chandra-Mouli V, Temmerman M. Sexual and Reproductive Health Research and Research Capacity Strengthening in Africa: Perspectives from the region. Reprod Health. 2015 Jul 31;12:64 46Michielsen K, De Meyer S, Ivanova O, Anderson R, Decat P, Herbiet C, Kabiru CW, Ketting E, Lees J, Moreau C, Tolman DL, Vanwesenbeeck I, Vega B, Verhetsel E, Chandra-Mouli V. Reorienting adolescent sexual and reproductive health research: reflections from an international conference. Reprod Health. 2016 Jan 13;13:3 47 Groen RS, Solomon J, Samai M, Kamara TB, Cassidy LD, Blok L, Kushner AL, Dhanaraj M, Stekelenburg J. Female health and Family Planning in Sierra Leone. Obstet Gynecol. 2013 Sep;122(3):525-31 48 Pieterse P, Lodge T. When free healthcare is not free. Corruption and mistrust in Sierra Leone's primary healthcare system immediately prior to the Ebola outbreak. Int Health. 2015 Nov;7(6):400-4. 49 Witter S, Wurie H, Bertone MP. The free health care initiative: how has it affected health workers in Sierra Leone? Health Policy Plan. 2016 Feb;31(1):1-9
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4.4.1 Implications for conducting a next survey Amendments had already been made in this second survey (based on the experience of survey1), and further methodological aspects deserve to be taken into account before the third round of surveys, if it takes place.
For conducting the household survey o The 4 intervention areas have lost their contrast o Difficulties to find the male and 20-24 years people at home at the time of the visit o Time constrains in relation to tight agenda o Improving questions on "union", on "literacy" o Exploring topics where change was unexpected such as distance to school, rape, payment, fear of condom. Some clarification will presumably be obtained from the colleagues at UNFPA o Keep the same clusters as in survey 2 o Keep conducting the analysis of direct exposure of VPE and CAGs for measuring the effect of UNFPA interventions o Consider finding resources for in depth analysis of data to allow dissemination and publication of the study results
For conducting the health facility survey o Bias of observation (the presence of the clinical observer may have influenced the actions of the provider) o Limited number of observations of Family Planning encounters (two per health facility) due to time constrains and small volumes of patients at the health facilities. o Consider revising the list of health facilities visited, with the aim to take out those of really difficult access, for example, Thelia in Koinadugu district, Mendekelema in Kailahun district, Ngepehun in Bonthe chiefdom (Bonthe district) and Sandaru in Penguia chiefdom (Kailahun district)
General aspects o The utilisation of electronic questionnaire and devices for data collection was satisfactory and gave “cleaner” data (no coding problem, less missing values, quicker transmission). We strongly recommend to continue using this method of data collection (as opposed to paper forms) in the future for all surveys, except for the observation of the client provider interaction. For the observation questionnaire we suggest to record the data on paper form while conducting the observation and transcribe it to the tablet, before leaving the health facility o For both surveys consider to allow one day training for supervisors and extend the training of enumerators if they are not experienced in the use of tablets
4.4.2 Policy and programme implications
Once again, the present set of surveys reaffirms the needs in Sierra Leone and the rationale for UNFPA of including Sierra Leone into the twelve countries with Global Programme on Reproductive Health Commodity Security stream 1 level of need.
Various issues have come up: some related to the effect of the EVD outbreak, some already identified in the previous survey, some new to this survey and some suggested by the literature, They are simply listed below.
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Better understanding the effect of EVD. In a study in Liberia50 serious disruption of antenatal care was reported Exploring better financial barriers in the context of -FHCI Better identification of distance barriers and of outreach Family Planning services Resources for fuller analysis of the databases; comparison with SLDHS 2013 Literacy is the best predictor of utilisation of condoms and contraception; however less than half the youngsters 10-14 can read; need to collaborate with school services? (same comment as in survey 1) Where does abstinence stand? The rape issue? Better exploring the wish for girls to be pregnant, especially in the lower age group Further explore the modalities of work of VPEs and CAGs. Among others, approaches that work best (i.e. the VPE from the community vs. the external one), what is the mix of skills that the VPEs or CAGs should have, how long should VPEs remain in each community?, which specific interventions they implement and how frequent these should be performed (i.e. talks. individual encounters)?. How does the VPE´s and CAGs approaches to their work compare with other similar programmes targeted to the young population 10-24. 4.5 Conclusion
This second survey provides follow-up data on the baseline survey conducted in 2014. It had been feared that the EVD outbreak would have very much disrupted the activities supported by the IRMNH programme and that there would have been deterioration of the indicators. Contrariwise, there has even been many improvements, including two which were statistically significant (for pregnancy rate and use of condoms by male). Observing no “statistical significance improvement” does not mean that there is no increase/improvement on the field. The changes observed were not enough to be significant with the design we choose and our sampled population.
The results confirmed the need to target the adolescent population, in addition to the men and women above 20, for strategies and interventions that will contribute to increase their uptake of Family Planning methods. It also confirms the need to work simultaneously on both supply side as well as demand side interventions. Additionally, the survey confirms that more needs to be known about the effectiveness of the strategies implemented, and what level of coverage is required to achieve an impact with those strategies.
It remains true nevertheless, that Sierra Leone, even for sub-Saharan Africa is a country with a very low index of human development. Inequalities are high, The IRMNH programme has potential to reach out to young people 10 – 24 years old effectively, targeting the most vulnerable.
The surveys contribute to further advancing the knowledge and understanding of the sexual and reproductive health needs of the young people of Sierra Leone, of the care providers and of the policy makers. This in turn can help in validating or adapting existing interventions or in developing new ones.
It should be noted that young people 10-24 years in Sierra Leone are exposed to many other reproductive health programs apart of the UNFPA interventions. The overall results of this survey should be seen as of all the various interventions and not only the UNPFA interventions.
50 Source: Iyengar et al. Services for mothers and newborns during the ebola outbreak in Liberia: the need for improvement in emergencies. PLoS. Curr. 2015 Apr 16;7
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ANNEXES
Annex 1. List of surveyed health facilities
Province District Chiefdom PHU name Facility Type Northern Koinadugu Dembelia - Sinkunia Sinkunia CHC Northern Koinadugu Diang Kelibaya CHP Northern Koinadugu Diang Lengekoro CHP Northern Koinadugu Diang Yarah CHP CHP Northern Koinadugu Diang Kondembaia CHC Northern Koinadugu Folosaba Dembelia Musaia CHC Northern Koinadugu Kasunko Fadugu CHC Northern Koinadugu Sengbe Dankawalie CHC Northern Koinadugu Sengbe Kamadu Sokurala CHP Northern Koinadugu Wara Wara Yagala Kabala Hospital (UFC) Hospital Northern Koinadugu Wara Wara Yagala Senekedugu CHP Northern Koinadugu Wara Wara Yagala Yataya CHC CHP Northern Koinadugu Sulima Falaba CHP Northern Koinadugu Neya Foria CHP Northern Koinadugu Neya Bambu Koro MCHP Northern Koinadugu Wara Wara Bafodia Thelia CHP Northern Koinadugu Mongo Seria MCHP Northern Kambia Magbema Rokupr CHC Northern Kambia Magbema Kambia Government Hospital Hospital Northern Kambia Samu Mapotolon CHC Northern Kambia Tonko Limba Kamagbewu CHP Northern Kambia Tonko Limba Kamassasa CHC Northern Kambia Tonko Limba Timbo MCHP Eastern Kailahun Kissi Teng Koindu CHC Eastern Kailahun Luawa Kailahun CHC Eastern Kailahun Luawa Kailahun Gov't Med. Hosp Hospital Eastern Kailahun Luawa Bandajuma Sinneh MCHP Eastern Kailahun Luawa Gbalahum CHP Eastern Kailahun Upper Bambara Mendekelema CHP Eastern Kailahun Upper Bambara Siama CHP Eastern Kailahun Upper Bambara Pendembu CHP Eastern Kailahun Yawei Bandajuma CHP Eastern Kailahun Yawei Bendu CHP Eastern Kailahun Yawei Foidu CHP Eastern Kailahun Kpeje West Pejewa CHP Eastern Kailahun Kpeje West Bunumbu CHP Eastern Kailahun Penguia Sandaru CHC Eastern Kailahun Kpeje Bongre Gbahama CHP Eastern Kailahun Kpeje Bongre Manowa MCHP Eastern Kailahun Njaluahun Follah MCHP
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Eastern Kailahun Malema Njama MCHP Eastern Kailahun Malema Jojoima CHC Eastern Kenema Kandu Leppiama Baoma Oil Mill CHC Eastern Kenema Kandu Leppiama Levuma (Kandu Lep) CHP Eastern Kenema Koya Baoma koya CHC Eastern Kenema Niawa Sendumei CHC Eastern Kenema Nongowa Gbo-Labayama MCHP Eastern Kenema Nongowa Gbo-Lambayama 2 CHP Eastern Kenema Nongowa Hangha CHC Eastern Kenema Nongowa Kenema Government Hospital Hospital Eastern Kenema Nongowa Koryagbema CHP Eastern Kenema Nongowa Largo CHC Eastern Kenema Nongowa Nekabo CHC Eastern Kenema Nongowa Ngelehun MCHP Eastern Kenema Simbaru Boajibu CHC Eastern Kenema Wandor Faala CHP Eastern Kenema Dodo Mbowohun CHP Eastern Kenema Dama Majihun MCHP MCHP Eastern Kenema Gaura Joru CHC Eastern Kenema Lower Bambara Tongo Field CHC Eastern Kenema Tunkia Ngegbwema CHC Eastern Kono Gbense Kono Government Hospital (KGH) Hospital Eastern Kono Gbense Gbangadu MCHP Eastern Kono Gbense Kamadu CHP Eastern Kono Koidu Town Kensay MCHP Eastern Kono Koidu Town Koakoyima MCHP Eastern Kono Mafindor Koindu Kutay MCHP Eastern Kono Sandor Kayima CHC Eastern Kono Tankoro Kimberdu CHP Eastern Kono Tankoro Kokyema CHP Eastern Kono Tankoro Timbadu CHC Eastern Kono Tankoro Woama MCHP Eastern Kono Lei Gongoifeh MCHP Eastern Kono Nimiyama Ngo Town CHP Eastern Kono Nimiyama Sewafe CHC Eastern Kono Nimikoro Motema CHC Eastern Kono Gbane Baoma MCHP Eastern Kono Gbane Gandorhun CHC Eastern Kono Gorama Komo Kangama CHC Southern Moyamba Fakunya Gandorhun CHC Southern Moyamba Fakunya Moyamba Junction CHC Southern Moyamba Kagboro Shenge CHC Southern Moyamba Kagboro Mokongbetty MCHP Southern Moyamba Kaiyamba Moyamba Government Hospital Hospital Southern Moyamba Kongbora Bauya CHC
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Southern Moyamba Kori Njala CHC Southern Moyamba Kori Taiama CHC Southern Moyamba Bumpeh Moyeamoh CHP Southern Moyamba Bumpeh Rotifunk CHC Southern Moyamba Bumpeh Bellentin CHP CHP Southern Moyamba Ribbi Bradford CHP Southern Moyamba Ribbi Suen CHC Southern Moyamba Timdale Mosanda CHC Southern Moyamba Kowa Mofombo CHC Southern Pujehun Kpaka Liya Kpaka CHP Southern Pujehun Malen Govt Hospital Pujehun Hospital Southern Pujehun Barri Potoru CHC Southern Bonthe Bonthe Urban Bonthe Government Hospital Hospital Southern Bonthe Bum Madina CHC Southern Bonthe Bum Ngepehun CHC Southern Bonthe Imperi Moriba Town CHC Southern Bonthe Imperi Mogbwemo CHP Southern Bonthe Jong Mattru Govt. Hospital Hospital Southern Bonthe Jong Jorma CHP Southern Bonthe Jong Gambia CHC Southern Bonthe Jong MATTRU CHC Southern Bonthe Kpanda Kemo Motuo CHC Southern Bonthe Sogbeni Tihun CHC Southern Bonthe Yawbeko Senehun MCHP
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Annex 2. Characteristics of respondents for the household survey
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Annex 3. Providers of Family Planning consultation by staff category and type of health facility, survey 2
Providers providing most of All Hospital CHC CHP MCHP Family Planning counselling session - survey 2 n % n % n % n % n % State Registered Nurse 1 SECHN 46 21.5 0 0.0 0 0.0 0 0.0 1 2.6 Registered Midwife 17 7.9 11 61.1 5 5.7 21 24.1 9 23.1 Enrolled Midwife 26 12.1 4 22.2 13 14.9 0 0.0 0 0.0 CHO 13 6.1 2 11.1 17 19.5 5 5.7 2 5.1 Community health assistant 10 4.7 0 0.0 13 14.9 0 0.0 0 0.0 Maternal and child health aide 99 46.3 0 0.0 5 5.7 4 4.6 1 2.6 Other 2 1 34 38 26
Total 214 100.0 18 100.0 87 100.0 87 100.0 39 100.0 * CHC: Community Health Centres; CHP: Community Health Posts ; MCHP: Maternal and Child Health Posts ;
SECHN: State Enrolled Community Health Nurse ; CHO: Community Health Officer
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Annex 4. Setting for the provision of Family Planning services by type of health facility, survey 2
Characteristics / Setting for the provision of Total (N=109) Hospital (N=9) CHC (N=45) CHP (N=36) MCHP (N=19) Family Planning services by type of health facility n % n % n % n % n % Family Planning services offered 109 100% 9 100% 45 100% 36 100% 19 100% Every day including weekend 73 67.0 1 11.1 26 57.8 29 80.6 17 89.5 Every day without weekend 23 21.1 3 33.3 13 28.9 6 16.7 1 5.3 Only on morning in week 1 0.9 1 11.1 0 0.0 0 0.0 0 0.0 Once a week 2 1.8 0 0.0 2 4.4 0 0.0 0 0.0 Other 10 9.2 4 44.4 4 8.9 1 2.8 1 5.3 Setting of FP offered 109 100% 9 100% 45 100% 36 100% 19 100% A room exclusively for FP 27 24.8 5 55.6 12 26.7 7 19.4 3 15.8 A shared room with other 76 69.7 4 44.4 30 66.7 28 77.8 14 73.7 Other 6 5.5 0 3 6.7 1 2.8 2 10.5 Setting of FP counselling. 109 100% 9 100% 45 100% 36 100% 19 100% Same room with clinical exam 87 79.8 6 66.7 38 84.4 26 72.2 17 89.5 Different room with clinical exam 22 20.2 3 33.3 7 15.6 10 27.8 2 10.5 Offering FP services during the Ebola 109 100% 9 100% 45 100% 36 100% 19 100% crisis Yes 98 89.9 6 66.7 41 91.1 33 91.7 18 94.7 No 11 10.1 3 33.3 4 8.9 3 8.3 1 5.3
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Annex 5. Availability of contraceptive methods on the day of the facility audit by type of health facility
Availability for all Availability of contraceptive methods HF Hospital (N=9) CHC (N=45) CHP (N=36) MCHP (N=19) on the day of the facility audit. by type of Health Facility . survey 2 N Yes N Yes N Yes N Yes N Yes Contraceptive methods n % n % n % n % n % Combined oral contraceptive pills 109 91 83.5 9 7 77.8 45 38 84.4 36 30 83.3 19 16 84.2 Progesterone only pill 109 108 99.1 9 5 55.6 45 29 64.4 36 10 27.8 19 2 10.5 IUD 109 46 42.2 9 5 55.6 45 25 55.6 36 10 27.8 19 3 15.8 Combined Injectables contraceptives 109 105 96.3 9 8 88.9 45 44 97.8 36 35 97.2 19 18 94.7 Progestin-only injectable 109 3 9 0 45 0 36 3 19 0 contraceptives 2.8 0.0 0.0 8.3 0.0 Implant 109 81 74.3 9 7 77.8 45 40 88.9 36 26 72.2 19 19 100.0 Male Condoms 109 109 100.0 9 9 100.0 45 45 100.0 36 36 100.0 19 17 89.5 Female condoms 109 66 60.6 9 3 33.3 45 31 68.9 36 22 61.1 19 10 52.6 * CHC : Community Health Centres; CHP: Community Health Posts; MCHP: Maternal and Child Health Posts
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Annex 6a. Health facilities with no stock-outs of contraceptive in the last 6 months by type of health facility, survey 2
Health facilities with no stock- out of contraceptives methods in the last 6 months by type of health facility, survey 2
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Annex 6b. Surveyed PHUS and hospitals with no stock-outs of contraceptives in the 6 and 3 months previous to the survey
Number and percentage of surveyed government PHUs and hospitals with no stock-outs of contraceptives in the 6 months previous to the survey (all types facilities) P- P- Survey 1 Survey 2 value* value** N n % N n % 1. Combined oral contraceptive pills 110 88 80.0 109 84 77.1 0.597 <0.001 2. Progesterone only pill 109 105 96.3
3. IUD 53 38 71.7 109 45 41.3 <0.001 0.013 4. Combined Injectables contraceptives 109 87 79.8 109 96 88.1 0.097 <0.001 5. Progestin-only injectable 25 14 109 4 contraceptives 56.0 3.7 <0.001 <0.001 6. Implant 81 61 75.3 109 62 56.9 0.009 0.211 7. Male Condoms 109 89 81.7 109 103 94.5 0.003 <0.001 8. Female condoms 84 59 70.2 109 69 63.3 0.312 0.070
Number and percentage of surveyed government PHUs and hospitals with no stock-outs of contraceptives in the 3 months previous to the survey (all types facilities) P- P- Survey 1 Survey 2 value* value** N n % N n % 1. Combined oral contraceptive pills 110 89 80.9 109 93 85.3 0.384 <0.001 2. Progesterone only pill 109 104 95.4
3. IUD 53 39 73.6 109 46 42.2 <0.001 0.022 4. Combined Injectables contraceptives 109 86 78.9 109 104 95.4 <0.001 <0.001 5. Progestin-only injectable 24 13 109 4 contraceptives 54.2 3.7 <0.001 <0.001 6. Implant 81 59 72.8 109 75 68.8 0.547 0.012 7. Male Condoms 109 86 78.9 109 105 96.3 <0.001 <0.001 8. Female condoms 84 62 73.8 109 70 64.2 0.155 0.028
Number and percentage of SDP with long acting Family Planning methods (IUD and implants) available on the day of the visit (N=110) P- P- Survey 1 Survey 2 value* value** N n % N n % All health facilities IUD 64 43 67.2 109 38 34.9 0.110 0.635 Implant 83 66 79.5 109 72 66.1 0.268 <0.001 *Chi-squared Test ; SDP: service delivery points; PHU: primary health units
**Adjusted by McNemar test. Only for the audit interview data. as the studies have been conducted in two time period in same health facility In statistics. McNemar's test is a statistical test used on paired nominal data. It is applied to 2 × 2 contingency tables with a dichotomous trait. with matched pairs of subjects. to determine whether the row and column marginal frequencies are equal (that is. whether there is "marginal homogeneity").
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Annex 7. Equipment at health facilities
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Annex 8. Number counselling actions performed by type of provider. reported by observer
Distribution of counselling actions performed by type of provider. as reported by observer. survey 2.
Maternal State Community Registered Enrolled and child No. counselling Registered SECHN CHO health Other All Midwife Midwife health actions Nurse assistant performed aide n n n n n n n N % 3 0 2 0 0 0 0 1 0 3 1.4 4 0 2 0 0 0 0 1 0 3 1.4 5 0 1 0 3 0 1 6 1 12 5.6 6 0 11 4 6 5 3 23 0 52 24.3 7 0 20 13 3 4 5 58 1 104 48.6 8 1 10 0 14 4 1 10 0 40 18.7 Total 1 46 17 26 13 10 99 2 214 100.0 SECHN: State Enrolled Community Health Nurse ; CHO: Community Health Officer
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Annex 9. List of staff involved in the survey
Name & last Name Position Email Phone number Household Survey Paul A. Sengeh Field Coordinator and [email protected] +23276626543 Supervisor Umu N. Nabieu Enumerator 076603475 Salamatu Sesay Enumerator 076591061/077659248 Mariatu Songo-Kanu Enumerator 076917988/077265506 Alusine Ahmed Bangura Enumerator 076754851/077 502280 Musu Dumbuya Enumerator 23276972676 Mirian K. Fornah Enumerator [email protected] 076 663215 Hawanatu Sheriff Enumerator [email protected] 232 79 123000 Philip Kemoh Enumerator 079946116 Francis Sengeh Enumerator [email protected] +23278469714 Sahr Hemore Enumerator 076956060 Nyaliema Mustapha Enumerator 079200484/088938505 Jermiah Kpaka Enumerator [email protected] +23276707720 Aloysius Mattia Enumerator 077516840 A.O.Bah Supervisor Andrew Kornneh Supervisor James Foday Sengeh Supervisor Health facility survey - team members Dr. Samuel A. Pratt Field Coordinator & [email protected] 076853055 Supervisor Aki Beckley Technical support & [email protected] supervisor Isata Kargbo Enumerator 76733126 Issiata Marah Enumerator 076553663 Sia Lebbie Enumerator 076746220 Mariama Charm Enumerator 088407880 Kadiatu Kamara Enumerator 076432679 Wullaimatu Conteh Enumerator 076762906 Maria Gboyah Enumerator 076227240 Iye M. Kamara Enumerator 076688065 Hawa Turay Enumerator 076945166 Bobson B.Fofana Enumerator 078758300 Christiana Caulker Enumerator 079632308 Memunatu Samura Enumerator 078441475 Focus Group Discussants Ibrahim Tucker Supervisor [email protected] +23278290685 Alhaji B Swanneh FGD facilitator/ Note [email protected] +23278807622 taker Gibrilla James Kamara FGD facilitator/ Note [email protected] +23276203569 taker Esther Momoh FGD facilitator/ Note [email protected] +23278624674 taker Juliana Thornton FGD facilitator/ Note [email protected] +23278614036 taker Other team members Mohammad B. Jalloh Responsible field work [email protected] 79 060 592 Mohammed F. Jalloh ODK development [email protected] Jan Franck Data processing / ODK [email protected] +4526885424 Supervisor Sophie Alexander SRH expert [email protected] Michèle Dramaix Statistician [email protected]
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Dalia Fele Data analysis [email protected] Aline Labat Data analysis / trainer [email protected] HHS Lilas Weber Data analysis [email protected] Weihong Zhang Family Planning expert [email protected] Marta Medina Team leader [email protected] +4526885426 Office Support Osman Bangura Logistics. FOCUS 1000 [email protected] Fatmata Logistics. FOCUS 1000 Gaia Calligaris Project officer. hera [email protected] +32 38445930
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Annex 10. Documentation available to the team
Adanu R. Mbizvo MT. Baguiya A. Adam V. Ademe BW. Ankomah A. Aja GN. Ajuwon AJ. Esimai OA. Ibrahim T. Mogobe DK. Tunçalp Ö. Chandra-Mouli V. Temmerman M. Sexual and Reproductive Health Research and Research Capacity Strengthening in Africa: Perspectives from the region. Reprod Health. 2015 Jul 31;12:64.
Belaid L. Dumont A. Chaillet N. De Brouwere V. Zertal A. Hounton S. Ridde V. Protocol for a systematic review on the effect of demand generation interventions on uptake and use of modern contraceptives in LMIC. Syst Rev. 2015 Sep 28;4:124.
BMJ 2015;351:Suppl1. Towards a new global strategy for women´s. children and adolescents. health. 2015.
Brolin Ribacke KJ. van Duinen AJ. Nordenstedt H. Höijer J. Molnes R. Froseth TW. Koroma AP. Darj E. Bolkan HA. Ekström A. The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone. PLoS One. 2016 Feb 24;11(2).
Dalaba MA. Stone AE. Krumholz AR. Oduro AR. Phillips JF. Adongo PB. A qualitative analysis of the effect of a community-based primary health care programme on reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana. BMC Health Serv Res. 2016 Mar 5;16(1):80.
Davis. Peter. July 2015. Ebola in Sierra Leone: Economic Impact & Recovery. UK Aid. Adam Smith International. Sierra Leone Opportunities for Business Action (SOBA).
Groen RS. Solomon J. Samai M. Kamara TB. Cassidy LD. Blok L. Kushner AL. Dhanaraj M. Stekelenburg J. Female health and Family Planning in Sierra Leone. Obstet Gynecol. 2013 Sep;122(3):525-31. hera/ULB/ESP/FOCUS 1000. Final Report Survey 1. Multi-Year Annual Survey to Monitor Programme Effectiveness of the “Improving Reproductive Maternal and Newborn Health (IRMNH) Programme”.Sierra Leone. Study commissioned by UNFPA. December 9. 2014.
Hounton S. Barros AJ. Amouzou A. Shiferaw S. Maïga A. Akinyemi A. Friedman H. Koroma D. Patterns and trends of contraceptive use among sexually active adolescents in Burkina Faso. Ethiopia. and Nigeria: evidence from cross-sectional studies. Glob Health Action. 2015 Nov 9;8:29737. https//:apps.who.int/ebola/ebola-situation-reports consulted on April 18. 2016.
IRMNH Annual Review Report 2016
Lopez LM. Grey TW. Tolley EE. Chen M. Brief educational strategies for improving contraception use in young people. Cochrane Database Syst Rev. 2016 Mar 30;3:CD012025.
Michielsen K. De Meyer S. Ivanova O. Anderson R. Decat P. Herbiet C. Kabiru CW. Ketting E. Lees J. Moreau C. Tolman DL. Vanwesenbeeck I. Vega B. Verhetsel E. Chandra-Mouli V. Reorienting adolescent sexual and reproductive health research: reflections from an international conference. Reprod Health. 2016 Jan 13;13:3.
Ministry of Health and Sanitation Sierra Leone. 2015. Health Sector Recovery Plan 2015 -2020. Ministry of Health and Sanitation. Sierra Leone Basic Package of Essential Health Services 2015 -2020. July 2015. Freetown. Sierra Leone.
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Annex 11. Useful numbers, survey 1 and survey 2
Variables Survey 1 Survey 2 Household survey Households, young people interviewed Number of households heads responding to the survey 1110 1172 Number of young people included in the survey (by age group) 10 -14 yrs 566 661 15 - 19 yrs 408 468 20 -24 yrs 314 280 10-24 yrs 1288 1409 Number of young people included in the survey (by sex) Females 689 757 Male 600 652 All 1289 1409 Married or in union, having had sex, ever given birth Number married or in a union (by sex) Male 99 64 Female 251 236 All 350 300 Number already had sex (by sex) Male 224 206 Female 353 381 All 590 587 Number ever given birth (female) 213 208 Family planning methods and sexual infections Number of modern FP users 223 249 Number who have had a STI in the past year 52 28 Number that looked for advice or treatment for this STI 42 26 Visited a health facility Number visited a health facility in the past year 465 388 VPEs Number of young people (10-24) reporting having met a VPE in the past year 10 -14 yrs 155 276 15 - 19 yrs 174 235 20 -24 yrs 103 108 10-24 yrs 432 619 Number of adolescents (10-19) reporting having met a VPE in the past year 329 511 Number of adolescents (10-24) who have met a VPE and already had sexual relations 214 269 Number of adolescents (10-19) who have met a VPE and already had sexual relations 122 168
Number of young people 10-24 that have met a VPE in the past year and reported using condom the last time they had a sexual intercourse 43 46
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Variables Survey 1 Survey 2
Number of adolescents (10-19) that have met a VPE in the past year and reported using condom the last time they had a sexual intercourse 27 25 CAGs Number of young people (10-24) reporting having met a CAG in the past year 10 -14 yrs 43 65 15 - 19 yrs 74 120 20 -24 yrs 80 114 10-24 yrs 197 299 Number of young people 10-19 reporting having met a CAG in the past year 117 185 Number of young (10-24) who have met a CAG and were referred to a health facility 36 28 Number of girls 10-19 who went to the health facility in the past year (whether they have met a CAG or not) 176 149 Health facility survey Health facilities, Family Planning clients Number of health facilities included in the survey 110 109
Number of Family Planning clients included in the survey (by age group) < 14 5 4 15-19 43 43 20-24 59 59 25-29 39 52 30-34 36 23 35-39 23 20 40-45 12 10 Missing 2 3 Total 219 214 Number of Family Planning clients included in the survey (by sex) Male 7 7 Female 211 204 Missing 1 3 All 219 214 Meeting VPEs and CAGs Number of Family Planning clients (12-45) reporting meeting a VPE in the past year 52 65 Number of Family Planning clients (12-45) reporting meeting a CAG in the past year 81 135
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