Changing Attitudes, Saving Lives. A Q&A with Dismas Damian

Globally, it is estimated that more than 220 million women in Low and Middle Income countries (LMICs) have an unmet need for family planning. Adolescents especially are some of the most at-risk groups for early pregnancy and parenthood. They face difficulties accessing contraception and safe abortion, as well as suffering from high rates of HIV and sexually transmitted infections. Various political, economic, and sociocultural factors contribute to poor information and access to services for this group. Among those are the attitudes of healthcare workers who often fail to provide young people with supportive, nonjudgmental, youth-appropriate services. 

But access to reproductive health services, including contraception, can often literally be a matter of life and death for adolescents, who are much more at risk of maternal mortality than other age groups. Complications during pregnancy and childbirth are the leading cause of death for 15–19-year-old girls around the world. For example, a recent study on maternal mortality in Tanzania found that women aged 20 to 29 years were 43% less likely to die from pregnancy-related issues compared to those younger than 20 years. One of the Sustainable Development Goals is to reduce their maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030. Because adolescents are a high risk group, improving access to family planning is a huge way this goal can be reached. 

Dismas Damian is a medical doctor and consultant who is working to increase adolescence contraceptive access in Tanzania. Dismas started his professional journey working in pediatric HIV programs. He was curious not just about the medical condition, but also how social norms influenced how people perceived and dealt with the condition. He soon realized that social perceptions and values were a huge factor influencing disease outcomes, and beneficiaries of health care programs needed to be included in the design to improve health care access. He is currently working with Pathfinder in Tanzania to implement programs that provide sexual and reproductive health care to adolescents. Yarrow Global had a virtual chat to talk about the unique needs of adolescent sexual and reproductive health, how health providers can make or break the success of a program, and why including adolescents in the design of a program is essential to making it work.

Yarrow Global: Tell me about how you first came to focus on adolescent contraception access and why it matters so much.

Dismas: From my experience working on HIV interventions I became really interested in adolescent interventions. I had an understanding that it could be a very key step to ending all these bad health outcomes or improving any health behaviors for the future.So I started working with several sexual and reproductive health organizations. But despite the investment sexual reproductive organizations have put into the country, the contraceptive use rate is still low, and it is the lowest among adolescents. The recent demographic survey in 2016 showed that one among four adolescent girls is already a parent or pregnant by the age of 19. So more than a quarter. That is not good news.

In addition to the early pregnancy and the teen pregnancy, there was also the issue of maternal mortality. Tanzania is among the countries with the highest rate of maternal mortalities. And a big contributor are the teen pregnancies because their organs are not fully grown,they have limited health knowledge, they are not accessing sexual reproductive services, and when they are pregnant and get complications they cannot access obstetrics and emergency services. So they are actually contributing to a large portion of these maternal mortality rates. 

When I was working for Marie Stopes International (one of the world’s largest family planning organizations) I learned about the concept of values clarification and  attitude transformation. It was initially  an International Planned Parenthood Foundation concept and it was used for reducing stigma for abortion services. In many countries, including Tanzania, it’s actually illegal to do abortion services. But you still have a very high number of post-abortion cases. And according to global and country reports, the prevalence of induced abortion is very, very high.

So we tried to sort of customize the value clarification and attitude transformation curriculum to also fit in the adolescent family planning. I was very interested to understand the impacts and designed a study to assess it. I actually wanted to understand the key individual dealing with day to day affairs of the adolescents, including health manager’s and educational managers. One of the barriers for adolescents not accessing family planning is because of social and religious taboos and customs. There is an explicit understanding that sexual acts should only be performed by people who are married. Outside of that, it is socially regarded as immoral. So when someone tries to access services and the service providers are also part of the community, they will often treat the adolescent, mainly young girls, like they are not supposed to be doing what they are doing. But adolescents are engaging in sexual acts and the statistics back that up. So my study was to understand the health managers’ perception of adolescents’ use of family planning services as these are responsible for ensuring access and quality of service for these adolescents. 

It was surprising that a majority of the people we had in that study believed that adolescents should not have access to sexual protective services, particularly family planning. The perception was that if you actually give family planning services to a young girl, it’s like sending a message to her that now you’re free to engage in sex, and create chances for promiscuity. So many people believed that, even the people at the highest levels of being responsible, district reproductive child health coordinators and such. So this was a huge barrier for adolescents to get sexually protective services and contraception.

I learned that this is sort of a bias in the health system itself, which identifies itself as the sole provider of sexual protective services to adolescents. There are guidelines on creating adolescent friendly services, but practically they are not represented because of all these taboos and complex social cultural issues. 

YG: Tell me how the Pathfinder project changed these biases.

D: The main goal is to increase access to these sexual protective services by adolescents. So we needed somehow to understand what would be a friendly environment, a friendly space for learning. The initial stages involved developing prototypes, which were very much adolescent-lead or adolescent-designed. We adopted a human-centered design where adolescents designed the prototypes of the model. We identified key barriers, also a category of components that needed to be addressed by this intervention. 

With the prototypes, we ended up having one which was feasible and implementable. The first thing was to introduce or expose providers to this reality, because the concept is if you’re not sharing the experience, you may not experience the gravity of the circumstances. 

The project operates through three pillars. The first is exposing the service providers into the adolescent’s experience called a “summit”. It gives the individual providers an opportunity to experience the reality of the adolescents through sharing and meeting with adolescents.The second pillar is actually sharing, “connect”. So the network between service providers sharing day to day experiences with each other and also other networks. We designed a blended approach whereby within the facilities, providers meet and discuss and share experiences between facilities and between facilities connecting through whatsapp.  And the third is pillar is “rewarding”. Using client exit interviews, facilities and individual providers were assessed against the Six Principles of Unbiased Care (safe welcoming space, sensitive communication, Seek understanding  and agreement, Say yes to a safe  method, Say yes to a safe  method and Security of information). The adolescents are involved in rating the particular facilities or individual providers. It is a very competitive process whereby facilities that did not perform well then actually get excited to perform in the next reward session. It’s not monetary, but now there are teaching certificates and it’s enough motivation for them and they are excited and actually keep improving each cycle.

YG: what are the lessons you learned from this project that you would want to share with other projects or programmes working on contraceptive access and adolescence?

D: What I actually learned was that we normally design projects based on our own thinking, based on our hypothetical description of the outcomes. We think of innovations without necessarily involving the beneficiaries. You might as a project think A is the way to go, but maybe the beneficiaries know for sure that C is the way to go. So in a way, we actually satisfy our own egos as project managers, our implementers, rather than actually doing a people-centered design that would benefit the beneficiaries.

But another very significant lesson is how people are moved when they are able to internalize circumstances. And what do I mean by this?  Among the exercises that we are doing on value clarification and attitude transformation was to position the same scenario, but in a different personal position. With this. I mean, we asked similar situations as if its the third person and it’s the first person. And I think this is human, but people tend to favor themselves. So this shows if you actually perceive for example an adolescent’s challenge, as if you were an adolescent yourself, you can provide better quality care. So that’s what I think I learned to be able to do-  to reinforce providers to try to put themselves in the shoes of the recipient so that they actually consider and design the services they would wish to be given. 

YG: Is there anything else about the project that I didn’t ask you about that you think is either really interesting or new or important to mention? 

Pathfinder is responsible for health services delivery and we are very much engaged with the health facilities. But in addition, we have community players. We have organizations that are very much directly dealing with peer educators. They engage adolescents in providing general sexual reproductive knowledge. You have people dealing with livelihoods. We have adolescents being organized in groups. They also engage in economic activity. You have adolescents being trained on a technology to provide a source of income. So we have different plans which actually are one. So we have these two sides which form a single picture, the different parts of each of the projects, but actually leading to the overall objective, which is improving access to sexual protective services by adolescents.

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