Acknowledgement

I wish to express profound gratitude to a number of individuals who have contributed to the success of this research project.

Firstly, to the Population Leadership Fellowship program at the University of Washington, Seattle, WA for facilitating the birth of this project from its embryonic stage.

To Dr. Stephen Gloyd, Director, International Health programme, for guiding my thought processes and in formulating this research project.

To Mrs. Vade Mohammed, Chief Executive Officer and Mrs. Emerald Leon Williams, Regional Nursing Officer, SWRHA for supporting the implementation of this project.

To Mrs. Lorraine Lutchman, Youth Officer, Victoria East, for your unselfish support in networking with a group of eight dedicated and enthusiastic youth from the community. Your support in facilitating the interview process with youth in the community was highly appreciated.

To the Ministry of Community Development Victoria East Division, for your support in facilitating the focus group discussion with community leaders. This was an invaluable support in providing credibility for the project.

To Miss Karen Sutton, Research Assistant, for your unselfish support in typing and collating data for analysis. Your enthusiasm and commitment were outstanding.

To Mrs. Joslyn Edwards, Coordinator, Community Care, Ministry of Health and your staff for sharing your expertise in Epi Info that facilitated the analysis of data.

To respondents who participated in the interviews and focus group discussions. Your charisma and personality was a source of inspiration to us all.

To my dear wife, Pauline Erva Craigwell-Ocho, for bearing with and encouraging me to complete the project, even when it meant not being at home often.

Finally, to God my never failing friend companion and guide who continues to inspire me

with a passion for success.

AcknowledgementsPage2

Table of ContentsPage 3

List of FiguresPage4

TitlePage 5

IntroductionPage5

Aims/ObjectivesPage5

Background And SignificancePage6

Literature ReviewPage6-7

Methods Page7-9

EvaluationPage9

AnalysisPage9

Data UtilizationPage9-10

Data PresentationPage11-24

Summary/ConclusionsPage25

RecommendationsPage26

BibliographyPage27

Appendix APage28-31

Appendix BPage32

Appendix CPage33

Appendix DPage34

Appendix EPage35
List of Figures

Figure 1

Age Group of RespondentsPage 11

Figure 2

Religious AffilaitionPage 12

Figure 3

Sexual and Reproductive HealthPage 13

Figure 4

Places for accessing SRH informationPage 14

Figure 5

Most influential factor for sexual activitiesPage 15

Figure 6

Risks to which adolescents and youth are exposedPage 16

Figure 7

Persons to offer SRH servicesPage 17

Figure 8

Most suitable place for offering servicesPage 18

Figure 9

Youth preference for offering servicesPage 19

Figure 10

Reasons for accessing servicesPage 20

Figure 11

Services that should be availablePage 21

Figure 12

Community groups supportive of servicesPage 22

Figure 13

Characteristics of service providersPage 22
TITLE:

Needs assessment for youth sexual and reproductive health services in a health region in Trinidad.

Introduction: The growing incidence of teenage pregnancy and Sexually Transmitted infections (STI), including HIV/AIDS amongst adolescents and youth in Trinidad and Tobago would have negative social and sustainable development impacts for the country. This group of individuals is vulnerable to the HIV/AIDS epidemic since they are involved in risk behaviors such as unprotected sex (Guttmacher, et al, 1995). However, many perceive themselves as being invulnerable (Rafferty, Radosh, 1997; Pleck, et al, 1996; Leighton, et al, 1996; Langer, et al, 1996; Brown, Pennylegion, Hillard, 1997). This is further exacerbated by sexual experimentation and exposure to pornographic information through expanding access to information technology via the Internet. Failure to act now in developing needs focused adolescent and youth sexual and reproductive health service could result in an unprecedented perpetuation and exacerbation of this problem.

International, regional and local organizations have advocated the need for implementing sexual and reproductive health services for youth (ICPD, 1994; UNFPA, 1998; FPATT, 2000). The Ministry of Health, through the Population Programme, has considered the need for incorporating such services in its strategic plan for the re-organization of sexual and reproductive health services. Senior members of staff from the Population Programme participated in a number of fora to ratify recommendations from the Regional Action Plan (RAP) from the post Caribbean Adolescent Rights (CAR) conference. These included the Caribbean Parliamentary Ministers of Youth and Health post CAR meeting, UNFPA report presentation post CAR in Trinidad and Tobago and the Ministry of Youth post CAR advisory board to implement the RAP. This department, established in 1969 to provide fertility management services, is well poised to develop such services due to its expanded vision. The department’s personnel are accessed as specialist resource personnel for training programmes in sexuality. Consequently, the quality of experience gained through training and service delivery are invaluable to making this transition successfully.

Aims and Objectives: This project aims to conduct a needs assessment for the establishment of an adolescent and youth sexual and reproductive health service in one health region in Trinidad and Tobago. The primary objectives are to

  1. Assess needs gaps related to SRH services for adolescents and youth within the present health system.
  2. Identify the scope of services necessary for implementing a quality adolescent and youth sexual and reproductive service,
  3. Assess the feasibility for establishing an adolescent and youth SRH service in one health region,
  4. Evaluate the capacity and potential demand for the provision of this service.
  1. Assess the feasibility of utilizing experiences from an established youth SRH service into this project.

As a result of this project, secondary objectives will be to

a)Assess the feasibility for implementing adolescent and youth sexual and reproductive health services as a core component of sexual and reproductive health services in all health regions in Trinidad and Tobago,

b)Evaluate the cadre of personnel needed as a baseline for the provision of these services.

Background and significance: The rising incidence of HIV/AIDS, especially amongst adolescents and youth, is a phenomenon requiring urgent attention.. Over the past two decades AIDS has become a global epidemic with serious social, economic and sustainable developmental implications. UNAIDS estimates suggested that there have been over sixty million people infected with HIV/AIDS, with fifty percent of the infections occurring in adolescents and youth, 15 – 24 years of age (Kiragu, 2001). IN fact one commentator has suggested that “today’s young people are the AIDS generation. They have never known a world without HIV” (Kiragu, 2001). Although multifaceted approaches have been used in various countries, this pandemic has continued to rise in an unprecedented way. The US Census Bureau postulates that if individuals do not begin to adopt responsible sexual behaviors, there will be more men of reproductive age than women, that would further exacerbate the risks for increased infection rates of HIV/AIDS amongst adolescent females. This potential problem is exacerbated by the assumption that males will seek younger females with whom to establish sexual relationships (Kiragu, 2001).

UNAIDS estimates that the Caribbean accounts for 130,000 persons between the ages 15 and 24 years living with HIV/AIDS (UNAIDS, 2001). The HIV/AIDS epidemiological data in Trinidad and Tobago also revealed a 5:1 female to male ratio for HIV infection in the 15-19 year age group (CAREC 1997).

Research data from a study conducted in the Caribbean by Pan American Health Organization showed that forty percent of the sample was sexually active by the age of ten years while another twenty percent became sexually active by the age of twelve years (PAHO, 1998). This data was further corroborated by research findings from a survey conducted in Tobago, which showed that most respondents had their sexual debut by the age of fifteen years (FPATT, 2000).

Literature Review:

Data related to sexual behavior amongst adolescents and youth show an increasing trend in their involvement in sexual activities without condoms (Rafferty, Radosh, 1997; PAHO, 1998; CAREC, 1997; Weeks, et al, 1997; Langer, et al, 1996; DiCenso, et al, 2001). Factors which affect their use of condoms include ability to experience pleasure, partner appreciation (Langer, et al, 1996; Pleck, et al 1996); perception of risks for contracting HIV/AIDS (Pleck, et al, 1996; Leighton, et al 1996; Langer, et al 1996: Brown, Pennylegion, Hillard 1997); preventing pregnancy (Langer, et al, 1996; Leighton, et al, 1996, Brown, Pennylegion, Hillard 1997); desire to be courteous with their first sexual intercourse but not necessarily for the others (Leighton, et al, 1996); use of oral contraceptive by female (Leighton, et al, 1996; Langre,et al, 1996) being unsure of partner’s HIV/AIDS status (Leighton, et al,1996) user friendly packaging (Brown, Pennylegion, Hillard 1997), peer pressure (Kiragu, 2001) or level of trust in the relationship (Langer, et al, 1996, Brown, Pennylegion, Hillard 1997).

There have been a variety of strategies initiated to address the problem of lack of condom use amongst this vulnerable population. Those initiatives have been propelled to a great extent by the level of advocacy for these services by youth activists and organizations. However, these have focused on the provision of services without a deliberate and comprehensive education component. Kirby (1992) argued “effective education leading to behavior change is currently the only method for reducing HIV transmission”. This is a fundamental factor that must be included since most initiatives in the past have focused mainly on the provision of contraceptive services in schools without a comprehensive education component. This project proposes to solicit perspectives from key stakeholders in the community that will contribute to the development of a comprehensive sexual and reproductive health service for adolescents and youth.

Methods

  • Theoretical Framework

The theoretical framework for this project is based on Social Cognitive Theory. In this theory “behavior is dynamic, depending on aspects of the environment and the person, all of which influence each other simultaneously (Baronowski, Perry, Parcel in Glanz, Lewis, Rimer, 1997). It emphasizes that while behavior is individualistic, it is affected by a number of factors which, when processed, determines one’s response. These factors include the environment in which the individual functions and the types of models of the particular behavior to which he is exposed. It also encompasses an individual’s perception of his capability to perform the particular behavior. However, this is influenced by the types of reinforcements associated with the behavior that is affected by one’s expectation and expectancy of the outcomes. Critical to an individual’s response to the behavior would be his perception of his self-efficacy. If an individual associates positive outcomes with behaviors, he would invariably associate positive values to the behavior resulting in a greater disposition to participate in the behavior. However, a perceived negative outcome would generally result in the opposite response to the behavior.

Sexual behavior, while individualistic, is influenced by a number of intrinsic and extrinsic factors. Adolescents’ biological development is associated with the development of psychosexual consciousness. These intrinsic factors coexist with external factors, such as the availability of information from a variety of media sources with both positive and negative messages. The socio-cultural environment in which the adolescent or youth is socialized has the capacity to reinforce this information or produce cognitive dissonance. However, the types of behavior modeled by adults and peers would influence their perceptions related to expectation, expectancy and self-efficacy of that behavior. The assumption upon which this framework is posited is based on the expectation that adolescents and youth would reduce sexual risk behaviors if the environment is supportive. This would encompass positive role models, positive reinforcement and formation of social networks.

  • Design

This needs assessment would be conducted in the Indian Walk district within the South West health region in Trinidad. This district was chosen because of its demographic characteristics and the availability of social support systems. The social support systems include Community Development Officers trained in relating to adolescents and youth and a youth support group sponsored by the Ministry of Youth which meets regularly. Participants would include adolescents and youth from the district, youth leaders, health professionals, non- health professionals and groups who offer adolescent and youth services. A random sampling methodology would be used for selecting participants. In the case of youth leaders and groups, a snowball sampling methodology would be used. Data collection would be done through personal interviews using an interview schedule and focus group discussions using an interview guide.

  • Activities

A variety of activities was initiated encompassing collaboration, training, data gathering and assessment of a youth health facility in another country. This project was conducted in two (2) phases.

In the first phase, a series of 3 focus group discussions was conducted with key stakeholders in the community. Each group discussion will comprise 15-20 persons and last for approximately 60-90 minutes. Each focus group discussion was held with stakeholders representing specific sectors of the community, including, youth, youth leaders, community leaders, health professionals and religious leaders. Care will be taken to ensure representation of demographic characteristics amongst participants. Factors that will be used to guide decisions for the inclusion of stakeholders include level of influence in the community, type of service offered and strategic position within the community, age and gender. This strategy was selected since it can be used as a forum for sharing information about the project and doing a stakeholder analysis. These meetings are based on the assumption that community participation in the development of an intervention will result in greater support for sustaining the intervention

In phase two, a number of activities were directed towards conducting the needs assessment. One skills workshop for data collection will be conducted for adolescent and youth interviewers. A total of eight interviewers with representatives based on gender and religious persuasion were selected to pursue the training. They were required to verbally agree to a contract as a prerequisite for training to maximize the project investment in their participation. Upon successful completion of the training and participation in the data collection activities, they all received a stipend. The district was stratified based on ethnicity and socio-economic status. A total of one hundred and forty nine interviews were conducted using an interview schedule. Participants between the ages of fourteen and twenty five years were selected using a random sampling methodology. The principal investigator and the research assistant conducted a total of three focus group discussions using an interview guide. Groups were developed using a number of criteria including in and out of school adolescents and youth, parents of adolescents and youth, religious leaders and involvement in adolescent or youth service delivery whether at the professional or non-professional level. The interviews were conducted by a group of eight youth who were recommended by the Youth Officer for Victoria East. They were given a stipend at the end of their data collection exercise. Participants for the three focus group discussions were selected by the ministry of Community Development and Ministry of Youth.

A visit to assess the Nagaru health service, a similar service in Uganda, was made during the month of March 2003 by the principal investigator. This visit provided the principal investigator with the opportunity to learn from the experience of other community-based approaches to sexual and reproductive health services for adolescents and youth. This organization was chosen based on its experience and the collaborative approach to service delivery. Data from the individual interviews and focus group discussions along with observations from the visit abroad will be shared with stakeholders at a special meeting. This meeting will be the catalyst for identifying stakeholders as members of a community advisory board who will be responsible for developing the strategic direction for the sexual and reproductive health service for adolescents and youth.

Evaluation

Monitoring of intervention activities will be a critical component of the evaluation strategy for this project. Interviewers will be required to complete interviews within 3 weeks from the start of data collection. Each interviewer would fill an output record form weekly. This will be used to monitor performance of each interviewer, identify potential problems or provide necessary feedback to them. Completed interview schedules will be transferred onto a spreadsheet on a daily basis. This will allow for preserving information on a timely basis and ensure accountability amongst interviewers. The Research Assistant will be required to fill out a weekly output record form for focus group discussions. This form will identify composition, number of persons present and duration of the focus group discussions.

Analysis

Data from the interviews were analyzed using descriptive statistics. Information from the focus group discussions was transcribed and verified by the principal investigator and research assistant. Themes were developed and the information from each focus group discussion was coded and assigned to the recurrent themes. This was used for analyzing the data qualitatively.

Data utilization

A special stakeholders meeting will be convened to discuss the final report. A community advisory board will be selected to begin the process of developing a sexual and reproductive health service for adolescents and youth consistent with recommendations from the report. The final report will be disseminated to the South West regional Health Authority (SWRHA) along with other stakeholders. Negotiations will be conducted with the SWRHA to implement a pilot sexual and reproductive health service for as proposed by the community advisory board for 1 year. The pilot service will be analyzed after the year. This unit will then serve as a model for the development of similar services in other health centers.

Data presentation

A total of 149 youth from the Indian Walk community were interviewed by 8 youth volunteers (See Table 1). The age of respondents ranged from under 15 years to over 45 years with the mode being 15 to 24 years. Most respondents, 83 were females, while 66 were males.

Figure 1