Were you delivering services to young people before the COVID-19 crisis?
In February 2019, Marie Stopes Uganda launched a peer-to-peer paper referral intervention, which was developed in partnership with behavioral science researchers at ideas42. Community-based mobilizers invited adolescents living in communities close to BlueStar[1] clinics to share “refer a friend” (RAF) cards with one another, alongside a reason why contraception might help them. Adolescents were invited to bring their cards along to facilities to redeem a wristband and to receive family planning counseling. Service providers were trained on how to provide adolescent-friendly care, waiting rooms were branded with posters to promote providers’ commitment to delivering non-judgmental adolescent-friendly care while posters in the counseling rooms displayed RAF cards brought in by adolescents to show that other adolescents use them. Trained service providers wore welcoming name tags and encouraged adolescents who are exiting services to take a card for a friend who might benefit from SRH information and services.
What new approaches did you use to respond to the barriers created by the COVID-19 pandemic to reach young people?
Due to the interpersonal nature of the refer-a-friend system, COVID-19 preventive measures like physical distancing and curfews challenged the supply and demand side of the interventions, making it difficult for adolescents both to refer friends and to access available health services. Knowing that young people are vulnerable to sexual exploitation and risky sexual behavior during the COVID-19 crises, we committed to continue reaching adolescents with information and services about SRHR.
To do this, we worked with behavioral scientists to design posters that incorporated SRHR information into messaging about protecting yourself from COVID-19. The messages were aligned with the government theme
Tonsemberera[2] to emphasize the importance of social distancing and personal hygiene. We used images and messaging that appeal to young people’s needs such as “Marie Stopes is here for you and your friends”, “We are open”, “Marie Stopes promises to serve you safely”, “Protect your future, avoid unintended pregnancies to keep your dreams alive’’.
The posters were distributed via village health teams and peer educators to BlueStar and MSI-supported public sector facilities throughout Uganda, including the facilities that had been using the refer-a-friend system. In addition, the project realigned funds to procure personal protective equipment (PPE) for service providers and mobilizers; capitalized on the existing SMS platform (Marie-text) to monitor performance and share information updates on MSI services; and finally provided remote supportive supervision to mobilizers to deliver COVID-19 and SRH integrated messages within their location of residence.
Why did you decide to use these approaches?
To build on the intervention design work that had been done to identify bottlenecks in adolescent-friendly care previously, we conducted a needs assessment of service delivery and adolescent client needs during the COVID-19 crisis. We found that women and girls were more likely to be at risk of sexual exploitation and may have an increased burden of caring responsibilities, making it harder to access SRH services.
The closure of schools had left adolescents idle in communities with no formal system to access information. Due to restrictions on movement and limited access to PPE, mobilizers had challenges with reaching adolescents in their communities. We found that many had perceptions of being at low risk of contracting the virus. Support was needed from the Ministry of Health (MoH) to engage communities on COVID-19 infection prevention. Some mobilizers were disseminating family planning messages during the MoH hand-washing promotions, although this was not well aligned. The mobilizers and service providers requested materials such as fliers and posters that could help in cascading uniform information quickly. This needs assessment informed the idea of using posters that could be easily distributed before curfew hours alongside the MoH COVID-19 handwashing promotions and health facility points like child-health clinics.
How are you working to find out if these approaches are having the desired impact?
In partnership with ideas42, we are evaluating the impact of the RAF card system using a randomized control trial. Preliminary findings show that facilities exposed to the intervention saw an average increase of six adolescent clients per month, compared to control facilities. The impact of all interventions to maintain access to adolescents during the COVID-19 pandemic, including the posters, is being monitored by tracking the percentage of adolescents seeking services in BlueStar facilities before, during, and after the pandemic. We were pleased to see that adolescents continued to make up at least 20% of BlueStar clinic clients during the pandemic. Despite the challenges we know adolescents were faced with, our client records show that the percentage of clients that were adolescents has steadily increased since February 2020.
