Transcript Exploratory Study of Attitudes and Communication Behavior

Exploratory Study of Attitudes and
Communication
Behavior of Providers in Youth
Friendly Clinics in Egypt
population council
2011
Dr. Hala Eldamanhoury
• A series of YFCs has been established between
2004-2008 . Today there is a total of 30 clinics
• According to MOHP policies, YFC providers
are not allowed to give physical
examinations to unmarried youth. They can
only provide information and counseling.
• Despite the need for youth SRH services, there
is evidence that those clinics are underutilized
Goal and Objectives
• To investigate the reasons underlying low
utilization of YFCs, with a focus on:
• Investigating communication behavior of
providers in YFCs in relation to sensitive
SRH.
• Examining providers’ attitudes towards
providing SRH services to youth.
• Identifying personal and institutional
factors that may interfere with SRH
services
Methodology
Study design
Qualitative study, applied a mixed methods
approach, in- depth interviews and debriefing
meetings with mystery clients
Study sample
10 YFCs (6 NGO and 4 MOH clinics).
20 in-depth interviews with a purposive sample of
providers (two providers per clinic)
Aim of the in-depth interviews :
• background characteristics,
• previous training and experiences,
• perceptions of different sensitive youth sexual
problems and reproductive health issues,
• and perceptions of barriers to utilization of
youth services
Two mystery clients were recruited (one male
and one female), to approach the clinics as youth
seeking RH services.
Male MC: 25 years old male seeking advice for
protection against STIs, in the discussion
he has had sex with several women in the past
six months.
Female MC: 24 years old unmarried female,
positive pregnancy test. She is afraid of revealing
this pregnancy to her parents for fear of
punishment.
youth mystery clients will provide
reports of
• interpersonal communication between
themselves and providers in the 10 sample
clinics.
• provider’s time with client,
• rapport building by provider,
• privacy for counseling during visit,
• ease and content of communication between
client and provider
Communication behavior of providers
as regard sensitive SRH issues
• Very few cases come to the clinics, one case /
week or less.
• Reasons: Inability to realize the importance of
these clinics, stigma, going to pharmacies and
private clinics
• As reported by 5 providers from both MOH and
NGO clinics:
“Youth with sensitive SRH issues, usually go to
private clinics not to these centers for seeking
more help and more privacy and confidentiality".
Most common complaints of the clients:
• Female clients:
menstruation, premarital concerns, infections, , breast
complaints, sexual harassment and masturbation
Virginity checks, termination of pregnancy, contraception.
‫ فا‬،‫"بنت جت هنا وقالت أنا بقعد العب في نفسي لحد ما أحس إن أنا أثرت‬
“‫عايزة حاجة تخليني أبطل‬
A girl came to me saying she “plays with herself” until she is
fully aroused …I want something to make me stop this!”
• Male clients:
how to avoid sexual desire and masturbation, semen
discharge and nocturnal emissions STIs or HIV/AIDS.
Reaction of providers to the
presented problem by MCs
• All the providers gave their personal opinion on what the
client should do, were judgmental and referred to religious
opinions.
• 10 providers asked the male client about symptoms and
signs of STIs
• The Female was advised to get married to the partner and
to keep the pregnancy
• The counseling sessions were different between male and
female clients.
Privacy for counseling the sensitive issues as
perceived by mystery clients
• Privacy and confidentiality were
breached in many facilities.
• No separate room for counseling
• Communicating the information
that the clients gave about
him/herself to others.
‫”زرت المكان ولم اجد الدكتورة وقابلتني اإلخصائية االجتماعية وحكيت لها‬
‫ وعندما عدت اتفاجئت ان ناس كثير‬،‫ وأعطتني موعد لمقابلة الدكتورة‬،‫حالتي‬
‫ قعدتني وقالت لزميلتها هو ده اللي انا حكيتلكم عن‬،‫عارفيني وعارفين حالتي‬
male M "‫حالته!! كان صوتها واطي بس انا سمعت‬
“I came to the clinic and didn’t find the doctor. I told the social
worker about my concerns – then I was shocked later that
everyone knew my story the next time I was there! They
were talking in low voice – but I heard”
‫ وقالتله تعالي يافالن اعرفك‬،‫ دخل ابنها األودة وفتح الباب فجأة‬،‫"اثناء المقابلة‬
‫علي (واشارت الي) وهو بيشتكي من حاجات كثير وخايف يكون جاله أي‬
"‫امراض منقولة جنسيا عشان ليه عالقات جنسية متعددة‬
”during the interview, her son came into the room – so she said hey
– come and join us (she pointed to me and said) see this guy – he
has so many complaints but is worried he might have contracted
HIV because he has multiple sexual relations.”
How providers see the youth clients
• Providers translate their roles as advocates and instructors, rather than
reproductive health care providers.
• The majority of providers refused to introduce help as regard the sensitive
issues
‫• "يعني وهى مش متزوجة طبعآ انا ال مش هديها يعني انا كده باشجعها انا اقولها مثال خدي وسيلة‬
!!‫ اشجعها على الرذيلة وال اعمل ايه‬...‫اهى وامشي براحتك هنا مكتب تنظيم اسرة حكومي محترم‬
• “Do you think, I have to give contraceptive method to an unmarried girle!!
So I am encouraging her to be sinful, this is a respectable governmental FP
center”
• Few Others have more pragmatic attitudes,
‫• لو بنت عندها عالقة ومحتاجة وسيلة لتنظيم االسرة عشان تمنع حمل غير مرغوب فيه؟) وهللا‬
‫ على أساس إن أنتي بردك ما‬،‫ وننصحها‬،‫احنا بنتكلم معاها وبنشوف هى بتعمل كده ليه‬
.“‫ كده هتخشي في حرمانية اكبر‬،،‫توصليهاش انها تحمل وبعد كده تدوري ان انتي تسقطيها‬
Providers’ opinions about youth SRH needs
• Youth need SRH services to know about
pubertal changes, counseling and reassurance
to deal with worries and wrong beliefs.
‫" عادي مش البنت ليها جهاز تناسلي زي أي واحدة البنت زي‬
" ‫ دي عرضة لإللتهابات ودي عرضة لإللتهابات‬،‫الست‬
• “It is normal, The girl has a genital system like
any Female, so if this will get infections, the
girl will be exposed to infection too.”
• General disapproval of adolescent pre-marital sexual
relations
‫هل ده اللي بتسموه امان؟‬- ‫ ده حرام‬، ?!!‫• ”يعني انا اوفر له عازل عشان مايتعديشن ده صح‬
‫ آجي في عيادة‬، ‫ انما انا ما اسهلش استخدامه‬،‫األمان اننا نمشي بشرع ربنا والشباب عارفينه‬
!‫صديقة للشباب واقول خد واقي‬
“‫أل طبعآ‬
do you mean to tell me I should provide him with condoms! Do you call
this safety?? This is sinful.. Safety is to follow God’s shara3.. I will never
make it easy for him.
‫• " احيانآ فيه بنات جم واتكلموا عن ممارسة العادات الغلط " عرفناها ان الحاجة دي حرام وانها لما‬
‫تالقي نفسها حاجة زي كده قلنالها قومي اتوضي واستحمي خدي دش بارد حاولي على اد ما‬
.“‫تقدري اتقربي من ربنا بالصالة مثال اصبري بكرة يجي سنك وهتتجوزي‬
• Some girls showed up telling us about bad practices. We
told them “you should wash and pray when this happens –
or take cold showers – try as much as possible to be close to
God with prayers. Eventually, time will come and you will
be married.”
Conflicts in managing those asking for termination of
pregnancy:
• 3 providers had conflicts in introducing help for termination
of pregnancy they believe that this is non religious and
illegal, but they relied on ‘an ethics of justice’
• 17 followed the legal roles and the clinic protocols in
different ways
"I didn't face any conflict; I do the things that I am convinced
with, and not haram.”
‫• " الحاالت اللي عايزة تصليح غشاء البكارة او تسقط سواء متجوزة وال أل‬
‫بتيجي كثير بأقول لها روحي بعيد عني وبفكرها بالدين هما عارفين اسامي‬
”‫الناس المتخصصة في الحاجات دي وستين حد يشور عليهم‬
Those asking for hymenoraphy, or abortion whether •
married or not, are many, I say to them go away!! I remind
them about the religion, They know where they can find the
providers of these things and many others could guide
them.
Experience of the mystery clients with
the providers attitude
• MCs described provider as unsupportive, positive attitude in 3
visits of the male and 2with the female.
‫ وصوت الدكتور كان عالي جدا وبيقول كده حرام اللي انت‬،‫"كنا قاعدين في الريسيبشن‬
“‫عملته ده غلط في حق نفسك ولم يحاول ان يناقش او يصاحبني هو زعق من األول‬
“While I was in the waiting room, the doctor came and talked to me
loudly, this is” haram” it is a big mistake, and he didn’t try to discuss or
be friendly”
‫• "حصل عالقة بيني وبين خطيبي وانا حامل وعايزة انزله عشان لسه مش هنتجوز‬
‫ اه؛ ال؛ احنا هنا مش بنعمل الحاجات دي وال أي‬:)‫ االخصائية (تغيرت نظرتها‬، ‫دلوقتي‬
‫حد من الدكاترة بتوعنا يقدر يعمل لك حاجة وبعدين عيادات الشباب مش بتاعت كده‬
"‫خالص‬
“my fiancée and I had sex. Now I’m pregnant. I want to abort.. The
social worker looked at me differently.. She said “oh no.. We don’t
do these things here.. Youth clinics are not for these things.”
Institutional factors
• Mystery clients had difficulty locating YFCs
‫"اعالنات كثيرة جدآ موجودة علي سور المستشفي عن صحة الشباب واألمراض المنقولة‬
‫ تفائلت لما لقيت كل اليفت دي وقابلت األمن وسألته عن العيادة اللي تبعها‬،‫جنسيآ‬
‫اليفت دي قال ما اعرفش روح الصحة اإلنجابية واسأل ولما رحت قالولي روح الفحص‬
” ‫قبل الزواج‬
“A lot of ads are hung all over the hospital walls, about youth and
sexually transmitted diseases. I got optimistic … when I asked the
guard about the clinic that provides these services, he said I don’t
know, you may go to the RH clinic. But when I went, they said you
may go to pre-marital examination clinic. “
Institutional factors
• Interviewed providers received many
trainings; but the majority of these trainings
were not on sexual or reproductive health of
youth related topics.
• Registration was incomplete in most clinics.
Majority of the providers said that they only
have forms for married women seeking family
planning or for those coming for premarital
counseling.
Institutional factors
• Providers stated that there were no written
guidelines rather they recognized some
because of their long work experience.
• A nurse in an NGO clinic outside Cairo said: “If
there is a protocol or policy to certain cases I
would follow and this will facilitate our work. ”
Conclusion
• Many barriers in meeting the needs of unmarried young,
not only because of the provider's negative attitudes
• Providers of SRHSs are located at a critical intersection
between the norms and values and the reality of
adolescent premarital sex
• Providers showed a rather pragmatic attitude towards
some reproductive health issues,
• What is contradicting, however, is that about 70% of
providers have approved of contraceptive use by sexually
active males, but the situation was different with females
Finally,
• Lack of seriousness of the providers &negative
attitudes represent a major obstacle in clinics
utilization as well as the institutional factors
• Providers are ill-equipped to address
adolescent sexual and reproductive health
issues.
• Improving quality of services in YFCs is an
urgent need
Challenges and study limitations
• Obtaining permits from officials
• Recruiting and training of mystery clients
• Due to the small number of YFCS in Egypt
there is a limited population for the study.
• Studies on attitudes are not easily
conducted and indicators to measure
attitudes and perform the analysis need larger
studies,
Thank You
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