School Health Nursing Programme for Adolescents

Nadia Ahmed HIV Foundation

INTEREST conference Kigali, Rwanda 2018 Background

• Adolescents need appropriate and accessible services. • School health nurses exist, but are lacking in secondary schools. • During this time issues around sexual and psychological health are more pressing as adolescents develop. • Services are needed that do not take them out of the learning environment for longer than needed. • The impact on health can be at a significant personal cost, lasting long into the future. Background

• School is protective for adolescents in terms of HIV, pregnancy -----> without which the risk increases! (1) • Limited data on similar programmes for secondary schools • Data from New Zealand, UK, USA, Hong Kong (2,3) • Integrated School Health Policy Department of Education SA (4) • Nurses from primary health care • Visit schools only once a year • Insufficient staff, time limits, lack of equipment & environment, rural • Exists but not translated into implementation…

1) Mason-Jones AJ1, Sinclair D, Mathews C, Kagee A, Hillman A, Lombard C. School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents. Cochrane Database Syst Rev. 2016 Nov 8;11:CD006417. 2) Buckley S1, Gerring Z, Cumming J, Mason D, McDonald J, Churchward M School nursing in New Zealand: a study of services.. Policy Polit Nurs Pract. 2012 Feb;13(1):45-53. 3) Lee RL1. The role of school nurses in delivering accessible health services for primary and secondary school students in Hong Kong. J Clin Nurs. 2011 Oct;20(19-20):2968-77. 4) www.education.gov.za Aim

• To offer adolescent youth friendly services (AYFS) as a school health nursing programme in secondary schools in , . Materials & Methods

• The School Health Nursing Programme is part of a bigger project called The Zimele Project. • Implemented by DTHF with the provincial and municipal department of health. The Zimele Project

• A multi-pronged prevention social and health intervention programme for ≈20 000 adolescents: predominantly adolescent girls and young women aged 10-24 years, both in and out of school.

Reduce New HIV Infections Keep girls in school Decrease teenage in girls and young women until graduation pregnancy incidence The Zimele Project: geared towards those in their 2nd decade of life

Keeping Girls in School: Health Education in School In Addition: Child Protection Services & In Addition: Rise Clubs Soul Buddyz Parents & Community dialogues with men

In Addition: Rise Clubs, Teen Parenting & PrEP Adolescent- tailored health services Women of Worth: Soul Buddyz Clubs: In Incentive & Care School Programme Age

10 years 14 years 19 years 24 years Impact evaluation Service utilisation Hub & Spokes Referral Model

• Hub: AYFS Clinic • Spokes: Schools, Mobile Units, School Health RNs, WOW, TPP etc • Model: • Linking services to health facilities • Health utilisation ✓ Operational Footprint: • 50 Primary Schools • 45 Secondary schools • 24 Health facilities • 10 Community Venues Secondary Schools N=45 Health Facilities N=24 Materials & Methods

• Secondary schools in Klipfontein and Mitchell’s Plain sub-district in Cape Town, South Africa were selected in collaboration with the provincial Department of Education. • Schools were selected based on: • location within the sub-district • having females in Grades 8-12 • student pregnancy data for the preceding three years. ABC Package

• Stakeholder relationships developed with schools, and the school health nursing programme was offered. • Permission for registered nurse to attend weekly to fortnightly offering a range of healthcare services to school learners. • Package of service was offered, with contracts with school. • Emergency advice available within school hours.

Sr. Boneta Smitsdorff Sr Phindile Matshini Sr. Beulah Classen Sr. Mariam Gqiza Mitchell’s Plain Philippi/ Crossroads Athlone/ Hanover Park Nyanga/ Gugulethu/ ABC Package Service Package Results accepted by School

• 40/45 secondary schools gave permission. 25% • 143 students seen (Feb – Mar 18). 42%

• 75% female (n=107). 33%

• Median age 16 years (range 8-21). Package A Package B Package C Results: HIV testing

• 49% (71/145) requested HIV tests. • 8/36 males • ALL were negative • Most common risk factor was not knowing partner’s status. Results: Pregnancy testing

• 62% (66/107) requested pregnancy tests. • 4 were positive • 2 requested terminations • 1 wanted to discuss the result with a parent • 1 referred to antenatal services. Results: Reasons for attendance 1% 1% Sexual and reproductive health (STI, menstruation, MMC) 4% Contraception (initiation, continuation, 8% side effects, breakthrough bleeding) Other 29% General wellness

35% Abuse (emotional, sexual) 22% Social issues

Mental health (depression) Results: Referrals

• 33% (12/36) males enquired about circumcisions. • A total of 30% (44/145) referrals were required • Local healthcare facilities (n=25), hospital (n=13), social worker (n=6). Conclusions

• Early preliminary data set. • Majority of students female; 51% requiring SRH needs. • Referrals needed for approximately one third. • Developing healthcare services within schools, brings healthcare direct to adolescents, enabling healthcare providers to reach them at a time and place more conducive to their daily life. • Facilitating their needs • Preventing them from missing school • Furthering their education and future possibilities Conclusions

• More on-site management (e.g. treatment of minor ailments) would facilitate adolescent healthcare by reducing need for referrals, thereby reducing the burden on current existing health services. • Intervening early with preventative measures can facilitate promoting positive health and well being. • Impact of education and linkage to health services is key. • Dependent on referrals system within area (AYFS healthcare clinics, Peer Navigators, Social Workers). Next Steps

• Multiple stakeholder involvement: • Other schools • Parents • Feedback from learners, principals and local services, nurses • Department of Health • Department of Education. • Continue to monitor. • Implement in other areas. • Community of practice – champions forum. “ Doc, they look at me and see hope !”

“The learners at the schools are faced with lots of social issues. Each week I have at least one learner that is sexually abused by a family member. They face peer pressure every day. I think the learners just needed someone they can trust and can open up to.”

“I really feel like I’m making a difference in the lives of learners.” Acknowledgements

• Beulah Classen • Boneta Smitsdorff • Phindile Matshini • Miriam Gqiza • Colleen Herman • Linda-Gail Bekker • The Zimele Team • Schools, Principals & School Learners • Department of Health • Department of Education