Zoyla Segura

Uncovering and responding to needs for sexual and reproductive health care among poor urban female adolescents in Nicaragua.

Background  To meet the needs of female adolescents from low‐income urban areas for sexual and reproductive health (SRH) care, vouchers providing free‐of‐charge access to SRH care at 19 primary care clinics were distributed in Managua, Nicaragua. These vouchers substantially increased the use of services, demonstrating that many adolescents are willing to use such services, if readily accessible. The voucher redemption made it possible to identify the nature of existing, but largely unmet, needs for SRH care.

Community embedded reproductive health interventions for adolescents in Latin America: development and evaluation of a complex multi-centre intervention

BackgroundAdolescents in Latin America are at high risk for unwanted and unplanned pregnancies, which often result in unsafe abortions or poor maternal health outcomes. Both young men and women in the region face an increased risk of sexually transmitted infections due to inadequate sexual and reproductive health information, services and counselling. To date, many adolescent health programmes have targeted a single determinant of sexual and reproductive health. However, recent evidence suggests that the complexity of sexual and reproductive health issues demands an equally multi-layered and comprehensive approach.MethodsThis article describes the development, implementation and evaluation design of the community-embedded reproductive health care for adolescents (CERCA) study in three Latin American cities: Cochabamba (Bolivia), Cuenca (Ecuador) and Managua (Nicaragua). Project CERCA’s research methodology builds on existing methodological frameworks, namely: action research, community based participatory research and intervention-mapping.The interventions in each country address distinct target groups (adolescents, parents, local authorities and health providers) and seek improvement of the following sexual health behaviours: communication about sexuality, sexual and reproductive health information-seeking, access to sexual and reproductive health care and safe sexual relationships.In Managua, we implemented a randomised controlled study, and in Cochabamba and Cuenca we adopted a non-randomised controlled study to evaluate the effectiveness of Project CERCA interventions, in addition to a process evaluation.DiscussionThis research will result in a methodological framework that will contribute to the improved design and implementation of future adolescent sexual and reproductive health interventions.Trial registrationClinicalTrials.gov (NCT01722084)

Improving adolescent sexual and reproductive health in Latin America: reflections from an International Congress

In February 2014, an international congress on Promoting Adolescent Sexual and Reproductive Health (ASRH) took place in Cuenca, Ecuador. Its objective was to share evidence on effective ASRH intervention projects and programs in Latin America, and to link this evidence to ASRH policy and program development. Over 800 people participated in the three-day event and sixty-six presentations were presented.This paper summarizes the key points of the Congress and of the Community Embedded Reproductive Health Care for Adolescents (CERCA) project. It aims at guiding future ASRH research and policy in Latin America.1. Context matters. Individual behaviors are strongly influenced by the social context in which they occur, through determinants at the individual, relational, family, community and societal levels. Gender norms/attitudes and ease of communication are two key determinants.2. Innovative action. There is limited and patchy evidence of effective approaches to reach adolescents with the health interventions they need at scale. Yet, there exist several promising and innovative examples of providing comprehensive sexuality education through conventional approaches and using new media, improving access to health services, and reaching adolescents as well as families and community members using community-based interventions were presented at the Congress.3. Better measurement. Evaluation designs and indicators chosen to measure the effect and impact of interventions are not always sensitive to subtle and incremental changes. This can create a gap between measured effectiveness and the impact perceived by the targeted populations.Thus, one conclusion is that we need more evidence to better determine the factors impeding progress in ASRH in Latin American, to innovate and respond flexibly to changing social dynamics and cultural practices, and to better measure the impact of existing intervention strategies. Yet, this Congress offered a starting point from which to build a multi-agency and multi-country effort to generate specific evidence on ASRH with the aim of guiding policy and program decision-making. In a region that contains substantial barriers of access to ASRH education and services, and some of the highest adolescent pregnancy rates in the world, the participants agreed that there is no time to lose.ResumenEn febrero de 2014, un congreso internacional sobre la promoción de la Salud Sexual y Reproductiva de los adolescentes (SSRA) tuvo lugar en Cuenca, Ecuador. Su objetivo era compartir evidencia sobre proyectos y programas de intervención eficaz en SSRA en América Latina, y vincular esta evidencia a la política de SSRA y al desarrollo de programas. Más de 800 personas participaron en un evento de tres días con sesenta y seis presentaciones.Este documento resume los puntos clave del congreso y del proyecto CERCA (Cuidado de la Salud sexual y Reproductiva para Adolescentes enmarcada en la comunidad). Su objetivo es orientar la investigación futura y la política de SSRA en América Latina.1. El contexto es importante. Los comportamientos individuales están fuertemente influenciados por el contexto social en el que se producen a través de factores determinantes a nivel individual, relacional, familiar, comunitario y social. Las normas de género, actitudes y facilidad de comunicación son dos factores determinantes.2. Acción innovadora. Hay evidencia limitada e irregular de los enfoques eficaces para llegar a los adolescentes con intervenciones que necesitan llevarse a escala. Sin embargo, existen varios ejemplos que fueron presentados en el congreso y que se ven prometedores e innovadores porque proporcionan una educación integral de la sexualidad a través de los métodos convencionales y el uso de nuevos medios de comunicación, la mejora del acceso a servicios de salud, y uso de intervenciones comunitarias para llegar a los adolescentes, familias y su comunidad.3. Mejor medición. Los diseños de evaluación y los indicadores elegidos para medir el efecto e impacto de las intervenciones no siempre son sensibles a los cambios sutiles y graduales. Esto puede crear una brecha entre la eficacia de medidas y el impacto percibido por las poblaciones beneficiarias.Por lo tanto, una conclusión es que necesitamos más pruebas para determinar mejor los factores que obstaculizan el progreso en la SSRA de América Latina, para innovar y responder con flexibilidad a los cambios en la dinámica social y las prácticas culturales, y para medir mejor el impacto de las estrategias de intervención existentes. No obstante, este congreso proporcionó un punto de partida para construir un esfuerzo común entre las multi-agencias y multi-país que genere evidencia específica sobre SSRA con el objetivo de orientar la toma de decisiones políticas y programas. En una región que aún tiene barreras de acceso a la educación y los servicios de SSRA y se encuentran las tasas de embarazo adolescente más altas del mundo, los participantes coincidieron en que no hay tiempo que perder.

Sexual onset and contraceptive use among adolescents from poor neighbourhoods in Managua, Nicaragua

Abstract Background and objectives The prevalence of teenage pregnancies in Nicaragua is the highest in Latin-America. This study aimed to gain insight into factors which determine the sexual behaviours concerned. Methods From July until August 2011, a door-to-door survey was conducted among adolescents living in randomly selected poor neighbourhoods of Managua. Logistic regression was used to analyse factors related to sexual onset and contraceptive use. Results Data from 2803 adolescents were analysed. Of the 475 and 299 sexually active boys and girls, 43% and 54%, respectively, reported contraceptive use. Sexual onset was positively related to increasing age, male sex, alcohol consumption and not living with the parents. Catholic boys and boys never feeling peer pressure to have sexual intercourse were more likely to report consistent condom use. Having a partner and feeling comfortable talking about sexuality with the partner were associated with hormonal contraception. Conclusions Our data identified associates of adolescents’ sexual behaviour related to personal characteristics (sex and alcohol use), to the interaction with significant others (parents, partners, peers) and to the environment (housing condition, religion). We interpreted those associates within the context of the rapidly changing society and the recently implemented health system reform in Nicaragua. Chinese Abstract 摘要 背景与目的 尼加瓜拉是拉丁美洲青少年妊娠率最高的国家。本研究旨在深入了解其性行为相关因素。 方法 2011年7月至8月，研究者在马那瓜贫困地区随机抽样，通过入户访视对青少年进行调查。统计方法采用Logistic回归，分析与性发生及避孕相关的影响因素。 结果 研究分析了2 803名青少年的数据。在475名与299名有性活动的男孩与女孩中，分别有43%与54%采取了避孕措施。研究表明，性发生与年龄增长、男性性别、酒精摄入及脱离父母独居等因素呈正相关。天主教男孩与从未感受到性交方面同侪压力的男孩会坚持使用避孕套。有性伴侣且可以与性伴侣坦然讨论性话题与避孕药的使用相关。 结论 研究数据表明，青少年性行为与个人特征（性活动及酒精摄入）、其他个体影响（父母、性伴侣、同侪）以及环境因素（住房条件、宗教）相关。我们认为这些相关性发生的背景为尼加拉瓜瞬息万变的社会环境与近期实施的医疗系统体制的改革。

Lessons learnt from the CERCA Project, a multicomponent intervention to promote adolescent sexual and reproductive health in three Latin America countries: a qualitative post-hoc evaluation.

Highlights • Large projects like CERCA require a preparatory phase and a thorough analysis of the situation at the country level as well as community-specific context information, to which sufficient time and budget should be attributed.• An essential part of community-based intervention and action research is to adapt the monitoring strategy if the interventions are changed and to thoroughly document all activities.• Accepting teenage pregnancies as a complex issue, not only means adapting interventions to this complexity, but also the evaluation design. In the case of the CERCA Project an overall evaluation should have included a component for each activity.• Further, the evaluation rightly addressed the effectiveness of the intervention package but should have extended this to address their acceptability, and factors that helped or hindered their application among all target groups and other stakeholders.• Through the concerted application of a multi-faceted strategy, it is possible to decrease the taboo on adolescent sexuality in a conservative setting.

Applying the results based management framework to the CERCA multi-component project in adolescent sexual and reproductive health: a retrospective analysis

BackgroundAdolescent sexual and reproductive health (SRH), problems such as unplanned pregnancies are complex and multifactorial, thus requiring multifaceted prevention interventions. Evaluating the impact of such interventions is important to ensure efficiency, effectiveness and accountability for project funders and community members. In this study, we propose Results Based Management (RBM) as a framework for project management, using the Community Embedded Reproductive Health Care for Adolescents (CERCA) as a case study for RBM. The CERCA Project (2010-2014) tested interventions to reduce adolescent pregnancy in three Latin American countries, Bolivia, Ecuador and Nicaragua. Activities were designed to increase adolescent SRH behaviors in four domains: communication with parents, partners and peers; access to SRH information; access to SRH services; and use of contraception. When the project ended, the outcome evaluation showed limited impact with concerns about accuracy of monitoring and attrition of participants.MethodsWe reviewed and analyzed a series of CERCA documents and related data sources. Key findings from these documents were organized within an RBM framework (planning, monitoring, and impact evaluation) to understand how CERCA methodology and performance might have reaped improved results.ResultsStrengths and weaknesses were identified in all three elements of the RBM framework. In Planning, the proposed Theory of Change (ToC) differed from that which was carried out in the intervention package. Each country implemented a different intervention package without articulated assumptions on how the activities of intervention would bring about change. In Monitoring, the project oversight was mainly based on administrative and financial requirements rather than monitoring fidelity and quality of intervention activities. In Impact Evaluation, the original CERCA evaluation assessed intervention effects among adolescents, without identifying success and failure factors related to the outcomes, the nature of the outcomes, or cost-effectiveness of interventions.ConclusionsThis analysis showed that multi-country projects are complex, entail risks in execution and require robust project management. RBM can be a useful tool to ensure a systematic approach at different phases within a multi-country setting.ResumenAntecedentesLa salud sexual y reproductiva de los adolescentes (SSR), como problemas de embarazos no planificados son complejos y multifactoriales, por lo que requieren múltiples intervenciones para su prevención. Evaluar el impacto de estas intervenciones es importante para asegurar la eficiencia, la eficacia y la rendición de cuentas para los donantes de proyectos y los miembros de la comunidad. En este estudio, proponemos la Gestión Basada en Resultados (o su sigla en inglés RBM) como un marco para la gestión de proyectos, utilizando el Community Embedded Reproductive Health Care for Adolescents (CERCA) como un caso de estudio para RBM. El Proyecto CERCA (2010-2014) puso a prueba las intervenciones para reducir el embarazo adolescente en tres países de América Latina, Bolivia, Ecuador y Nicaragua. Las actividades fueron diseñadas para mejorar los comportamientos adolescentes en SRH en cuatro aspectos: comunicación con padres, compañeros y pareja; acceso a la información sobre SSR; acceso a los servicios de SSR; y uso de anticonceptivos. Cuando el proyecto terminó, la evaluación de resultados mostró un impacto limitado sobre todo por la precisión en el monitoreo y pérdidas en el seguimiento de cohortes.MétodosSe revisó y analizó una serie de documentos CERCA y fuentes de datos relacionados. Las principales conclusiones de estos documentos se organizaron en el marco lógico de la Gestión Basada en Resultados (planificación, monitoreo y evaluación del impacto) para comprender cómo la metodología y el rendimiento de CERCA podrían haber obtenido mejores resultados.ResultadosSe identificaron fortalezas y debilidades en los tres elementos del marco de RBM. En la Planificación, la propuesta Teoría del Cambio (ToC) difiere de la que se llevó a cabo en el paquete de intervención. Cada país implementó un paquete de intervención diferente sin supuestos articulados sobre cómo estas actividades de intervención producirían cambios. En el Monitoreo, la gestión del proyecto se basó principalmente en requisitos administrativos y financieros en lugar de supervisar la fidelidad y la calidad de las actividades de intervención. En la Evaluación de Impacto, la evaluación original del CERCA evaluó los efectos de la intervención entre los adolescentes, sin identificar los factores de éxito y fracaso relacionados con los resultados, la naturaleza de los resultados o el análisis de costo-efectividad de las intervenciones.ConclusionesEste análisis mostró que los proyectos multinacionales son complejos, implican riesgos en la ejecución y requieren una gestión del proyecto sólida. La Gestión Basada en Resultados puede ser una herramienta útil para garantizar un enfoque sistemático en las distintas fases de un proyecto bajo un contexto multi-país.