CERCA aims to develop a framework for health systems to improve the responsiveness to the sexual and reproductive health needs of adolescents. The interventional research is based on the hypothesis that a comprehensive strategy of community-embedded interventions helps to meet the SRH needs of adolescents. The CERCA project will test this hypothesis and describe the development, implementation and testing of intervention strategies and related factors. The settings are cities in Bolivia, Ecuador and Nicaragua.
The interventions are targeting at improved access to adolescent-friendly health services, an enabling environment and strengthened adolescent competence to make reproductive health choices. The use of internet and text message on mobiles will be studied as gateway to reach adolescents. Policy makers are continuously involved in the research as a part of the project strategy to bridge the gap between research and policies.
Adolescents in Latin America are confronted with serious sexual and reproductive health (SRH) problems. Studies show that most of the adolescents younger than 20 years have had sexual intercourse with different partners without taking any precaution for preventing sexually transmitted infections (STI) or pregnancy. Up to 50% of the women in the region give birth for the first time during their adolescence and a significant proportion of these pregnancies are unwanted. Early and unwanted pregnancies - which are much more frequent among poor segments of society - are linked to school drop-out and have been steadily increasing among unmarried persons or those not in a stable relationship. Between 10 and 21 percent of hospitalisations for complications arising from unsafe abortion occurred among adolescents.
Adolescent health programmes tend to focus on unidirectional interventions aiming at reducing adolescents’ risky behaviours (to prevent unwanted pregnancies and HIV/STI infections), but adoption of healthy reproductive health attitudes and behaviours does not happen in a vacuum. Adolescent reproductive health strategies to improve access to reproductive health information and services are critical, but not sufficient. Hence a comprehensive approach is needed. Adolescents require motivation and ownership to make healthy decisions about their reproductive behaviour. Family and community support are crucial in this context and mobilisation of parents, community leaders and local institutions are essential strategies in SRH programmes focussing on adolescents.
The “community-embedded reproductive health care for adolescents” research is based on the hypothesis that a comprehensive strategy of community -embedded interventions helps to meet the SRH needs of adolescents. Those interventions are targeting at improved access to adolescent-friendly reproductive health care in primary health services, a supporting and enabling environment and strengthened adolescent competence to make reproductive health choices.
The CERCA project will test this hypothesis and describe the development, implementation and testing of intervention strategies and related factors in selected research settings in three Latin American cities: Cochabamba in Bolivia, Cuenca in Ecuador and Managua in Nicaragua. Based on these results, a framework will be developed for health system interventions to improve the responsiveness to the health needs.
The CERCA project aims to contribute to the global knowledge about how health systems could be more responsive to the changing sexual and reproductive health needs of adolescents.
In a first phase - the situation analysis - data were collected from different documental sources: statistical data at local level (civil registration, reports of health centres, household surveys etc.), national level (national health information systems, demographic and health surveys etc.) and international level (WHO/PAHO, UNFPA, World Bank, etc.). Apart from these documents additional information was obtained through qualitative research, including focus group discussions, in-depth and semi-structured interviews, and also a collaborative ethnographic method.
The findings of the documental research were described in three country reports and a global comparative report on the determinants of SRH of adolescents. The most important determinants identified through the documental research are: education level, residence, human development, poverty, GDP per capita and budget for SRH, prenatal consultation and health care personnel in health centers, indigenous and non-indigenous condition and cultural aspects.
The results of the qualitative research were presented in internal reports and will be incorporated in future scientific articles. Following key issues emerged repeatedly: the taboo on abortion, the use and misuse of internet for information on SRH, the gap between what health service providers think they are offering young people in terms of education and information on sexual and reproductive health issues, and what young people think they need, the impact of migration and the stigmatization of homosexuality, the intergenerational transmission of norms (e.g. the value of virginity), the discrepancy between the romantic ideal and the daily reality. The perspectives of health providers on barriers for adolescent SRH are described in the articles “Primary health care providers’ views on improving sexual and reproductive health care for adolescents in Bolivia, Ecuador and Nicaragua” (approved for publication by the peer reviewed journal Global Health Action) and "Barriers for adolescent SRH care from the perspective of primary health care providers of Ecuador, Nicaragua and Bolivia" (in review process with a peer reviewed journal).
In the three countries the health providers pointed out several aspects related to socio-cultural factors and norms interfering with the provision of quality SRH care to adolescents. They mentioned religion, taboo on sexuality, poor communication skills and the persistent myths as barriers for adolescents to address themselves to SRH services. However, it is striking that the health providers did not reflect on how their own personal perspectives and norms are crucial for their attitudes and behavior towards adolescents consulting for their SRH. Another remarkable fact is that health providers have prejudiced views on adolescents which they seem not to be aware of. Those prejudgments might be a hampering factor for their communication with adolescents.
The results of the documental review and the qualitative research guided the development of questionnaires for quantitative surveys. These surveys were carried out among 3519 students in Bolivia, 2403 in Ecuador and 2803 in Nicaragua. All participating adolescents were between 14 and 18 years old. The results of the quantitative analyses improved our knowledge of the sexual and reproductive health situation of the adolescents involved in the research project. One of the important outcomes of the survey is that positive attitudes towards gender equality are related to a happy and more healthy sex life of adolescents in Bolivia and Ecuador. These results will be discussed elaborately in an international peer reviewed article that will be submitted to the international journal Global Health Action by December 2013.
In a second phase of the project, a comprehensive strategy for community-embedded interventions was developed, implemented and monitored. These processes were based on the research results of phase 1 and on a methodological model which incorporates three methodological frameworks: action research, community based participatory research and intervention mapping. The CERCA consortium opted to develop this model in order to best meet existing adolescents’ SRH needs, to ensure community ownership and participant empowerment, and to be responsive to changing political and socio-cultural context. A detailed description of the methodology applied in the Cerca project has been published in an international peer-reviewed journal: “Decat P, Jaruseviciene L, Orozco M, Ibarra M et al: Community embedded reproductive health interventions for adolescents in Latin America: development and evaluation of a complex multi-centre intervention. BMC Public Health 2013, 13(1):3”.
With the research on community-embedded reproductive health care for adolescents, the CERCA consortium partners will deliver a high-quality public good (a framework for health interventions) with impact on the sexual and reproductive health of adolescents in Latin America and with health policy relevance for other countries and health issues.
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