Strengthen knowledge, attitude and practices (KAP) on sexual and reproductive health (SRH) among adolescents (Experimental) – Effective access to sexual and reproductive health education and services can lead to increase in contraceptive usage, along with overall agency of adolescent girls. This strategy leveraged the Rashtriya Kishor Swasathya Karykram (RKSK)- the only government programme which offers the unique opportunity to work with adolescents on SRH both in and out of school.
It adopted a user-centred approach to design and demonstrate a new model to effectively engage with adolescent under RKSK. It further leveraged learning from CIFF’s Adolescents 360 project that will be adapted to the Rajasthan context.
The approach had the following elements: 1) Working with the adolescent to understand their real life experiences, needs and generate ‘insights on programming (inspiration and ideation) 2) Prototyping a range of cost effective and scalable interventions 3) design and pilot the most promising interventions .
Approach: Human Centred Design
A good design is innovation and intersection of 3 areas: desirable (human), viable (business), and feasible (technology). Project Udaan adopted a Human Centric Design (HCD) to facilitate a process that regularly involved the users and key stakeholders to make sure the final solution remains relevant to them.
It aimed to improve Knowledge, Attitude and Practices (KAP) amongst unmarried adolescents regarding sexual and reproductive health (SRH). HCD enabled:
The development of the intervention using HCD commenced with an immersion workshop. Post this formative research was conducted- to understand the KAP around SRH among adolescents in the community. This in turn assisted with the concept strategy finalisation (ideation) and field testing the same (rapid and live prototypes) for the final pilot implementation model.
Immersion Workshop (October 2018 – November 2018)
As a result of early identification of the limited HCD programming capacity, an immersion workshop arranged to enable a clear comprehension of the application Human Centric Design (HCD) approach for the programming. A participatory four-day training workshop was held in Dholpur. This provisioned a hands-on experience of HCD process steps. Partners were oriented on interviewee skills and tools to gather field visit insights. They were further trained on synthesizing of field insights. Moreover, brainstorm and create, and field test and thereby, refine prototypes.
Formative Research (December 2018- January 2018)
In addition to the initial situation analysis, there was a need for a comprehensive adolescent centric formative research in Dholpur district. This was then later validated in Barmer and Udaipur, to gain a better understanding of the requirements of AH programming in socio-culturally sensitive environments. The objective was to understand SRH needs and health seeking pattern among adolescents; to further curate plans and coordinate activities from an adolescent’s perspective. Over 500 key stakeholders participated in the exercise, that included- adolescent boys and girls, parents, gatekeepers, PRIs, schools, cosmetic shops, beauty parlours, chemists, and locals. The District Programme Manager, RKSK District Coordinators and counsellors participated in this formative and validation exercise. They provided feedback and suggestions with respect to the probable challenges and strategies that could create a conducive environment for AH strategy selection.
As a result of this, we identified five adolescent user archetypes with different unmet SRH needs due to gender, life stage, mobility, and other socio-cultural factors. This is due to several inflection points and shifts in aspirations and motivations. These five profiles were found to be representative of distinct SRH needs and ‘high’ risk contexts. Following are the key findings that influence an adolescent’s SRH related KAP-
Misconceptions and lack of awareness around issues of contraception, available ASRH services, myths around masturbation and nightfall, among both adolescents were reported.
Parents and family members like elderly, uncles and sister-in-law and in the community like peers, teachers, principals and media/mobile shop owners were identified important influencers. These influencers create social sanction and a culture of permission without which adolescents might not have any agency or incentive to change their current SRH KAP.
In absences of proper channels, mass media shared especially by peers played a significant role in influencing gender norms and attitudes among adolescents. The chances of falling prey to negative stereotypes and SRH behaviour is then found higher, given peer pressure.
Lack of motivation to seek SRH information at Ujala Clinics – It was discovered that Ujala clinic counsellors failed to capitalize on key moments of service interaction with adolescents. Adolescents were hesitant to seek help at the clinics or outreach programmes. This is because parents always accompanied the adolescent to an Ujala clinic, which further hampered open conversations. Adolescents suggested chemists as quick and discreet with supplies to mitigate their SRH related concerns. Demand generation for Ujala clinics through school camps and adolescent health days suffers due to mobilization and resource constraints. This elevated by the fear of community backlash given the nature of activities. It also prevented last mile connectors like ASHAs and ANMs from participating effectively within the system. Moreover, much of the existing programmatic communication provided at Ujala clinics on AH, especially SRH, was found to be superficial, prescriptive, and did not address the real issue. Furthermore, adolescents preferred doctors/private clinics where their privacy could be maintained.
Schools were considered safe spaces to access SRH related information.
Ideation Workshop (March 2018)
Comprehending the research findings, a two-day ideation workshop was conducted to identify best strategies that could be re-iterated in the field. For this, formative research results were synthesized, to arrive at opportunity areas that could be leveraged for the implementation model. Around 60 ideas were generated with respect to how to reach to adolescents and influence SRH behaviour among them. These ideas were aligned to the project’s key outcomes, feasibility, cost-effectiveness, accessibility, and ability to integrate with RKSK. Adolescents, health service providers, and community members were the identified key stakeholders. Further consultation with the government and key stakeholders- partners and community, three broad buckets of models were selected to start with field testing namely, Youth +; Ujala 2.0; and collective action.
With respect to Youth + the key idea revolved around- creating safe spaces for adolescents and integrate SRH information into broader narrative of their lives in a fun and youth-centred way. The ideas included improving phone-based counselling experience, addition of interactive features for the same; and creation of content related to AH with a special focus on SRH, that is informative and easily accessible to adolescents.
The ideas for Ujala 2.0 emphasized on improving the quality of ASRH services provisioned by Ujala Clinics and increase demand for counselling among adolescents. This included improving the clinic experience, designing of counselling tools for counsellors, ASHAs and ANMs. To create demand ideas revolved around increasing awareness of Ujala services and helpline services available for adolescents; increasing referrals to Ujala clinics, creation of trained peer educators, and short internships at Ujala clinics to increase the number of trained peer educators.
Under Collective Action, ideas focused to improve knowledge of safe SRH practices among adolescents, challenge social norms arounds early marriage and address gender biases in the community. For the same, ideas revolved around improving the experience of Adolescent Health Days (AHDs) at schools through sports and activities, organising community events like nukkad nataks and sport activities to break the culture of silence around important AH topics and break gender stereotypes.
In addition, activities for rapport building at the policy level took place. A meeting was conducted with the Managing Director of National Health Mission to share the results of the ideation. A state level consultation with District RKSK counsellors, RCHO, was also organised.
Rapid and Live Prototyping (April 2018 – August 2018)
The next step involved, monitored field testing of the key ideas generated during the ideation, over multiple iterations. The objective was to answer to the initial questions of relevance, acceptability, and scalability of the would-be intervention model. During the rapid prototype phase, interactive contents with respect to the six RKSK identified themes were prepared. Ujala counsellors were trained for the in-school delivery of the same.
During the live prototype phase, three key activities namely, Ujala Mitra (In-school programme), Khel Saathi (Sports and film- based programme) and Ujala Khel Saathi (In-school and Khel based programme), were undertaken. Sport sessions included game sessions like satolia with adolescent boys and girls. Further, exposure visits of adolescent boys and girls to the Ujala clinics was organised. Importantly, in-school SRH sessions was conducted in 2 identified senior secondary schools of Basai Nawab village of Saipau block of Dholpur.
As a result of prototyping, following interactive intervention activities from an adolescent's perspective were identified for the pilot intervention:
In-school component – Schools proved to be safe spaces to create positive KAP around SRH topics and Ujala services. The key activities planned revolved around-
Ujala Clinics- To strengthen the supply to ASRH needs, following activities were planned-
Marketing the Ujala Brand - To encourage demand, -
Adolescent Helpline- Activities were planned to improve the helpline counselling experience by creating a knowledge bank (text and audio) for the counsellors and outlining SOPs. This included - counsellor training and creation of a helpline repository.
Create co-gendered community spaces- Out of school interventions were found to be resource intensive with sustainability as a key issue. It was difficult to transact SRH information during sports sessions and film screening due to resistance from the community.
However, this component was kept under consideration, given the need for community mobilisation to create awareness and support.
Only 42 percent adolescent girls in Rajasthan with 12 or more years of education had correct knowledge of specific sex and pregnancy related matters. Lack of access to reproductive health information and services are leading drivers of teenage pregnancies in the world.
In order to counter this, Udaan piloted an Adolescent SRH program in 66 government schools (Class 9 to 12) in Bari block of Dholpur district. Most of the blocks in Dholpur are largely rural with low levels of awareness. The block borders Chambal, a region known for dacoits, and as a result, people live in apprehension, especially when it comes to sending girls to school at a distance. The district also has a large Scheduled Caste (SC) population (20.4%). According to NFHS-4, it is one of the districts with the highest incidence of early marriages in the state. It has the third highest adolescent fertility rate (8.7%), fourth lowest contraceptive use (53.7%), and the highest (16.4%) need for family planning in the state.
Hence, Udaan adopted Human-Centric Design approach to design high impact sustainable models for improving adolescents’ knowledge on sexual and reproductive health.
Human Centered Design is a process that regularly involves the users and key stakeholders to make sure the final solution remains relevant to them.
HCD is adopted to:
IPE Global worked on improving knowledge, attitude and practices around sexual and reproductive health among adolescents in Rajasthan. The initiative adopted a Human Centric Design approach and integrate the efforts within National Adolescents Health Programme.
The execution plan (standard operating procedures) discussed below is from our project popularly known as “Udaan TaRa”, which was piloted across 66 schools for two years and later scaled up to 567 schools in Rajasthan.
The Department of Health and Family Welfare (DoHFW) is the major stakeholder for achieving the SDG goals and is also primarily responsible for ensuring the ARSH education across India. Department of School Education (DoSE), Department of Panchayati Raj and Department of Rural Development (DoPR&RD), Department of Women and Child Welfare (DWCD) are the other key stakeholders to be taken onboard for implementation of ARSH education programme. These efforts led to the formation of a panel of ARSH experts and prepare orientation tools on the need for ARSH education. The panel list down various topics would be transacted as part of the curriculum, to avoid participants imagining their own content.
The journey of Udaan TaRA is mentioned below: