Factors which influence the effective delivery of demand generation interventions for sexual and reproductive health services among adolescents in Sierra Leone

Background The Improving Reproductive, Maternal and Newborn Health (IRMNH) programme has been working in Sierra Leone since 2012.Among its areas of focus, IRMNH aims to ‘generate demand’ - or increase awareness and use of sexual and reproductive health (SRH) services - among adolescents.To guide these efforts, Partnership Management, Evaluation and Learning (PMEL) and the Directorate of Reproductive and Child Health in the Ministry of Health and Sanitation commissioned a piece of research to identify the factors that influence effective demand generation interventions for SRH services among adolescents (aged between 10 and 18) in Sierra Leone and other low- and middle-income countries (LMICs).MethodsThe research was conducted in three stages:

1. A structured literature review of demand generation interventions in Sierra Leone and LMICs;
2. An analysis of secondary data on the specific factors which influence demand-generation in Sierra Leone;
3. Collection and analysis of primary qualitative data, including fifteen focus group discussions with adolescents in three districts in Sierra Leone (Pujehun, Western Area, Bombali), and 36 key informant interviews with stakeholders (including health facility staff, community leaders, parents/guardians, and local politicians). All data was analysed thematically and fed into the development of a ‘Framework for Action’.

Key findings

• Respondents felt that teenage pregnancy was the most pressing issue to tackle among adolescents. Other pressing issues included sexually transmitted infections (STIs) and unsafe abortion, and less commonly early marriage; gender-based or domestic violence; HIV; menstrual problems; fistula; and Female Genital Mutilation (FGM) were discussed;
• Drivers of SRH problems included transactional sex due to economic pressure; misconceptions about family planning; inadequate access to family planning or condoms; inadequate access to testing and treatment services; lack of knowledge; peer pressure; and family pressure;
• Barriers to adolescents accessing services included cost; distance; bad roads; lack of confidentiality; maltreatment by health care workers; inadequate supplies, drugs, or infrastructure; and inadequate community support;
• Effective demand-generation interventions included youth-friendly training and upgrades at facilities, as well as some or all of the following:
  • Community-based provision of STI treatments, family planning and condoms
  • Radio, drama or community-based education
  • Interventions focusing on structural change, for example aiming to keep adolescent girls in school through gender equality interventions, financial and material support
  • Peer education in communities or in schools
  • Community sensitisation
  • Supporting out-of-school adolescent girls to build their skills to support themselves and avoid transactional sex
• General recommendations for demand generation interventions for adolescents are laid out in the ‘Framework for Action’.

ConclusionThe Ebola outbreak had a devastating impact on service use with a rise in SRH problems such as teenage pregnancy among adolescents. Most demand generation interventions were gratefully received by adolescents, with the only criticisms being that they were sporadic; unsustainable; not adequately monitored; or not suitable for all adolescents. The most effective demand-generation interventions included both ‘supply-side’ service-strengthening and demand-generation aspects, as well as a ‘bridging’ aspect focusing on the referral process.To read the report, click here.Options Consultancy Services Ltd: Partnership Management, Evaluation & Learning (PMEL). (2016). Factors which influence the effective delivery of demand generation interventions for sexual and reproductive health services among adolescents in Sierra Leone: lessons learned and a framework for action. Freetown/ London: Partnership Management, Evaluation and Learning/ Options Consultancy Services.