Young women and abortion

Young women and abortion:

A situation assessment guide

ISBN: 1-933095-68-7 © 2011 Ipas.

Produced in the United States of America.

Suggested citation: Ipas. 2011. Young Women and Abortion: A situation assessment guide. Chapel Hill, NC: Ipas.

Ipas works globally to increase women’s ability to exercise their sexual and reproductive rights and to reduce abortion-related deaths and injuries. We seek to expand the availability, quality and sustainability of abortion and related reproductive health services, as well as to improve the enabling environment. Ipas believes that no woman should have to risk her life or her health because she lacks safe reproductive health choices.

Ipas is a registered 501(c)(3) nonprofit organization. All contributions to Ipas are tax deductible to the full extent allowed by law.

Cover photos: top, © Ipas; bottom © Richard Lord; Back cover: © Richard Lord The illustrations and photographs used in this publication are for illustrative purposes only. No similarity to any actual person, living or dead, is intended.

For more information or to donate to Ipas: Ipas P.O. Box 5027 Chapel Hill, NC 27514 USA 1-919-967-7052 ipas@ipas.org www.ipas.org Editor: Margie Snider Graphic designer: Kristin Swanson Printed on recycled paper.

Ipas Youth Program

young women and Abortion: A situation assessment guide

By Evelina Borjesson, Jessica Izquierdo, Anna de Guzman, Deborah McSmith, and Laura Villa

ii

Young Women and Abortion: A situation assessment guide

TABLE OF CONTENTS ACKNOWLEDGEMENTS

1

ABOUT THIS GUIDE

2

1. INTRODUCTION

7

1.1 Why conduct a situation assessment on young women and abortion?

7

1.2 What is a situation assessment and when do you do it?

9

1.3 How do you use this situation assessment guide?

10

1.4 What assessment methods does this guide include?

11

1.5 References

12

2. PLANNING A SITUATION ASSESSMENT

13

2.1 Defining learning objectives

13

2.2 Gathering demographic and epidemiological data

14

2.3 Selecting situation assessment sites

18

2.4 Gaining community endorsement and support

19

2.5 Identifying effective facilitators

21

2.6 Identifying community participants

23

2.7 Selecting assessment methods

26

2.8 Making an assessment budget

28

2.9 References

29

2.10 Resources

29

3. IMPLEMENTING A SITUATION ASSESSMENT

31

3.1 Fulfilling participants’ rights

31

3.2 Preparing each session

34

3.3 Facilitating each session effectively

35

3.4 Recording and reviewing information

38

3.5 Monitoring assessment progress

39

3.6 Resources

40

Table of contents

iii

4. USING THE SITUATION ASSESSMENT METHODS 4.1 Focus group discussion

41

4.2 In-depth interview

46

4.3 Reproductive health life line

50

4.4 Social network circle

55

4.5 Resource mapping

62

4.6 Situational drawing

64

4.7 Resources

73

5. FINALIZING A SITUATION ASSESSMENT

75

5.1 Compiling your assessment data

75

5.2 Analyzing your assessment data

76

5.3 Using your assessment data

80

5.4 Disseminating your assessment findings

81

5.5 Maintaining your relationship with assessment partners and community members

81

5.6 Resources

82

Appendix A: A situation assessment in ‘Tuva’

83

A.1 Defining learning objectives

83

A.2 Selecting situation assessment sites

84

A.3 Identifying community partners

84

A.4 Identifying community participants

85

A.5 Selecting assessment methods

86

A.6 Focus group discussion questions

86

A.7 In-depth interview questions (for sport club coaches)

89

A.8 Resource mapping questions

89

A.9 Situational drawing questions

90

A.10 Compiling your assessment data

91

A.11 Analyzing your assessment data

92

A.12 Using your assessment data

93

Appendix B: Sample situation assessment report outline

iv

41

94

Young Women and Abortion: A situation assessment guide

ACKNOWLEDGEMENTS The authors would like to express their gratitude to everyone who provided support and guidance in the conceptualization, development, piloting and review of this guide. We are particularly grateful to Cecilia Espinoza, who provided invaluable inputs during the evaluation and review of the guide and offered assistance in translating documents and feedback from Spanish-speaking colleagues. We extend our deep appreciation to all the Ipas country teams and partners who piloted the guide, including Ipas Central America, Ipas Nepal, Ipas Nigeria, Ipas South Africa, Bhaktapur Youth Information Forum and Society for Local Integrated Development, Nepal. A team of Ipas technical reviewers provided substantive, thoughtful feedback and insightful recommendations: Leila Hessini, Cindy Geary and Kristen Shellenberg.

Thanks also to the Ipas Resource Center team – Julia Cleaver, Allison Long, Elese Stutts and Jean Vollrath – for their valuable assistance in locating the many references reviewed for the evidence-based recommendations.

The authors would like to acknowledge the following Ipas teams and partners who participated in the evaluation of the guide and contributed their time to provide valuable feedback and recommendations: Ipas Central America: Marta Maria Blandon, Dayra Gutierrez and Karen Padilla Zuniga Ipas Nepal: Madhabi Bajracharya Ipas Nigeria: Ejike Oji, Sarafina Ojimaduka, Mathew Okoh, Ezenwa Nwizugbe and Chudi Ene Ipas South Africa: Buyile Buthelezi and Errol Nkonko Ipas USA: Cecilia Espinoza Bhaktapur Youth Information Forum: Shreejana Bajracharya Society for Local Integrated Development, Nepal: Deepa Chapagain, Rohan Lal Chaudhary, Dr. Khem Karki and Arjun Subedi

Acknowledgements

1

ABOUT THIS GUIDE This guide was created to help ensure that programs related to abortion care are accessible to and appropriate for young women (ages 10 – 24). It is a global resource for community groups, youth groups, peer educators, trainers, administrators, program managers and technical advisors of abortion care programs. It is designed to gain insights into the local context surrounding abortion care for young women to inform program design and to support meaningful youth participation in project design. The guide provides stakeholders experienced in participatory action research, needs assessments and similar processes with the background information, materials, instructions and tips necessary to effectively execute situation assessments on the topic of abortion and youth.

Background Young women have the same human, sexual and reproductive rights as other people (UN 1948, 1966, 1989, 1999, 2003, 2009, 2011; UNESCO 1995; UNFPA 1995). These rights include information, health and freedom from discrimination based on age, gender or other characteristics. Safe, respectful abortion information and care are essential to ensure young women’s sexual and reproductive health and wellbeing. But around the world, young women face unique social, economic, logistical, legal and health systems barriers to sexual and reproductive health and rights (SRHR) information and care, including safe abortion (Olukuyo et al. 2001, Turner et al. 2011). Their rights are often neither recognized nor upheld.

Age, sexuality and abortion-related stigma, lack of supportive social networks, negative provider attitudes and gender issues are all examples of barriers that impact young women’s ability to act on their sexual and reproductive health decisions. These various barriers also impact abortionrelated knowledge and behavior at the interpersonal, community and organizational level, and can influence effectiveness and sustainability of any given program. The often-sensitive context surrounding abortion care for young women can make it difficult to design programs that reflect their realities and support their meaningful participation. A culturally appropriate assessment of community needs, experiences and recommendations can maximize effectiveness and sustainability of a program and establish participatory processes.

Focus The focus of this guide is on assessing how young women and their communities relate to abortion, through locally relevant, community and/ or youth-led processes. The intention is to ensure that young women are able to access SRHR and abortion-related information and care, to which they are rightfully entitled, in ways that are effective and appropriate according to them and with their meaningful participation. This guide does not specifically address abortion care for young women. Information on delivering and ensuring access to appropriate abortion care for young women can be found in Ipas’s toolkit, Abortion Care for Young Women: A training toolkit (Turner et al. 2011). This guide provides information and tools on identifying and removing barriers to abortion information and care for young women within the local context and in a participatory manner.

The information gathered through use of this tool can be used to ensure that programs respond to young women’s circumstances and reflect the needs and opportunities for change identified by young women. The guide

2

Young Women and Abortion: A situation assessment guide

focuses on formative research, community engagement and partnership building rather than on program delivery itself.

Development In 2010, Ipas developed a pilot guide, Young women and abortion: A guide for conducting situation assessments using participatory methods, to explore young women’s needs, realities and experiences related to SRHR, particularly abortion. In 2010-2011, pilot assessments using the guide were conducted in select communities by four Ipas programs: Nepal, Central America, Nigeria and South Africa. Ipas staff from the Youth Program in North Carolina provided initial training and introduction to the situation assessment guide. Ipas staff and partners in-country were responsible for facilitation of daily assessment activities and engaging key community members. After the pilot assessments, an external consultant was contracted to conduct an evaluation of the guide. Ipas staff and partners responsible for piloting the situation assessment guide responded to a written evaluation questionnaire and participated in verbal follow-up, the latter lasting approximately 45-60 minutes per participant.

Their feedback was incorporated in an evaluation report (Ipas 2011, internal document), which was used to revise this guide prior to its final publication and wider dissemination.

Intended audiences The primary audiences for this guide are community groups, youth groups, peer educators, trainers, administrators, program managers and technical advisors of abortion care programs. Assessment facilitators should be identified based on their familiarity with participatory action research methodologies and the local community, and on their ability to access the designated population either directly or through partners. It is essential that facilitators also have knowledge in SRHR and abortion-related issues prior to conducting an assessment. A foundation in these areas is necessary in order to be able to effectively implement the participatory methods while also serving as a knowledgeable resource to participants. When facilitators do not have sufficient background in these areas, pre-assessment capacity building is recommended (see Chapter 3). A capacity building event can also provide important opportunities for assessment team building among adult and young facilitators, note takers and other team members. This guide was developed within a global context and should be tailored to specific contexts and audiences to meet the needs of the local population.

Adaptations Sociocultural norms and laws that influence a young woman’s ability to access SRHR information and care, including safe abortion, vary between and within countries and communities. Although this often proves challenging when designing locally relevant programs, this guide emphasizes participatory methods that aim to make youth and abortion programs more culturally and socially acceptable and participatory. However, advance preparation and background research are necessary. Facilitators should gather information on national and local laws and policies, sociocultural norms, demographic and epidemiological data, service delivery practices, appropriate mediums for communication and other considerations. Review of this information will then inform the selection and/or adaptation of the assessment methods based on applicability to the local community. The assessment methods in this guide (see Chapter

About this guide

3

4) can be used as they appear together; in circumstances where this is not appropriate in the local context, facilitators are encouraged to use the methods separately. Facilitators, therefore, must weigh the value of the information gained by each method against the barriers to, and the costs of, conducting the method.

Please share your experiences using this guide! Your comments and recommendations can be sent to the Ipas Youth Program at youth@ipas.org.

4

Young Women and Abortion: A situation assessment guide

References Olukoya, A.A., A. Kaya, B.J. Ferguson and C. AbouZahr. 2001. Unsafe abortion in adolescents. International Journal of Gynecology & Obstetrics.

75: 137-47.

Turner, Katherine L., Evelina Borjesson, Amanda Huber, Cansas Mulligan.

2011. Abortion Care for Young Women: A training toolkit. Chapel Hill, NC: Ipas.

United Nations (UN). 1948. Universal Declaration of Human Rights. New York: UN. United Nations (UN). 1966. The International Covenant on Economic, Social and Cultural Rights. New York: UN. United Nations (UN). 1989. Convention on the Rights of the Child. New York: UN. United Nations (UN). 1999. Report of the Ad Hoc Committee of the Whole of the Twenty-first Special Session of the General Assembly, including Key Actions for the Further Implementation of the Programme of Action of the International Conference on Population and Development (A/S-21/5/Add.1).

New York: UN. United Nations (UN). 2003. General Comment No. 4: Adolescent Health and Development in the Context of the Convention on the Rights of the Child (U.N. Doc. CRC/GC/2003/4). New York: UN. United Nations (UN). 2009. General Comment No. 12: The right of the child to be heard (CRC/C/GC/12). New York: UN. United Nations (UN). 2011. Committee on the Rights of the Child 56th Session, Concluding Observations: Ukraine, advanced unedited version.

New York: UN. UNESCO. 1995. Beijing Declaration and Platform for Action, Fourth World Conference on Women. New York: UN. UNFPA. 1995. Report of the International Conference on Population and Development, Cairo, 1994. New York: UN.

About this guide

5

6

Young Women and Abortion: A situation assessment guide

1. INTRODUCTION This chapter shows how situation assessments are a useful tool for highlighting the realities that young women face in their communities. You will become familiar with youth-specific issues related to abortion, and begin to identify important questions that may be answered through the assessment methods. This introduction to the format of the guide and the methods will help you as you move throughout the next four chapters.

1.1 Why conduct a situation assessment on young women and abortion?

There are more than 1.7 billion young people aged 10-24 in the world (PRB 2006)—the largest population of young people in history. Their sociocultural environment and circumstances are changing, which can affect the likelihood of unwanted pregnancy and abortion. For example, many young women are now staying Data on young women’s sexual and in school longer, migrating further away from reproductive health, including their birth place, entering the workforce in abortion larger numbers and marrying later (Bremner • Each year, 14 million women aged 15 – et al. 2009, Turner et al. 2011). Girls are also 19 give birth. On average, one third of reaching puberty earlier than in previous women in developing countries give birth before age 20. (Rowbottom 2007) decades (WHO et al. 2006). The time period during which young women may be unmarried • Pregnancy and childbirth-related complications while also able to become pregnant is therefore are the leading cause of death for women aged 15-19. Nearly 70,000 adolescent girls die every expanding (Cook and Dickens 2000, Singh year and at least 2 million more are left with et al. 2000). Pregnancy and motherhood chronic illness or disabilities. (Rowbottom 2007) outside of marriage are stigmatized in many societies, which may cause young, unmarried • Adolescent girls (ages 10 – 19) in developing countries undergo 2.2 to 4 million unsafe pregnant women to seek abortion. Other abortions each year (WHO 2004). reasons young women may choose abortion that are independent of marital status include a • Worldwide, adolescent girls make up 70 desire to continue education; an unsupportive percent of all hospitalizations from unsafe abortion-related complications (Plan 2007). or absent partner; inadequate resources; the pregnancy resulted from violence or abuse; • Young women (ages 10 – 24) account for health risks; or the woman does not want to approximately 46 percent of unsafe abortionbecome a mother at that time, or at all (Turner related deaths each year (WHO 2004). et al. 2011).

Young women have a right to SRHR information and care, including safe abortion. But there are many social, economic, logistical, policy and health system barriers to safe abortion care for young women. Barriers include stigma, negative attitudes, fear of negative repercussions, lack of access to comprehensive sexuality education, limited financial resources, cost of services, transportation, involvement laws and concerns over privacy and confidentiality (Olukoya et. al. 2001, Turner et al. 2011). They explain why young women Defining young women often find no alternative other than to resort Ipas uses the operational definition of young to unsafe abortion, even in settings where people as people aged 10 – 24 years. This range safe abortion is legal. These violations of corresponds to the UNFPA and WHO definitions young women’s rights, and the high number of young people. We are mindful that girls sometimes reach puberty, or are forced to become of young women who continue to resort to sexually active, at a younger age. Depending unsafe abortion, make it critical to ensure on the objective of your assessment, it may be that all young women have access to SRHR useful to adapt your definition of young people information and care, including safe abortion, to the local setting and/or distinguish between married and unmarried young women. in their communities in ways that are effective and appropriate for them.

1. Introduction

7

Young people are the main experts about their own lives. They know what issues and barriers affect them most in their communities. They know what their preferences are, and what kinds of messaging and programs resonate with their peers. They are aware of their capacities and limitations to change things, as well as their fears and desires.

Programs and policies that address young people’s needs must be informed by youth perspectives. In doing so, they will be much more successful (Youth Coalition 2009). For example, health-care providers and managers partnering with young people to define high-quality health care are better able to meet young people’s needs and encourage positive care-seeking behaviors (Save the Children 2008). Implementing community and youth-generated solutions could mitigate or eliminate barriers that young women face when trying to access safe abortion care (Turner et al 2011). Since each new generation of young people brings about changes in beliefs and behaviors, related to diverse areas such as sexuality and communication technologies, we need to understand Young people on participation the specificities of each generation of “Nothing for us without us.” young people, in their local setting. This ––South African peer educators’ mantra understanding will help programs to address “We the children are experts on being 8, the barriers young women face in preventing 12 or 17 years old in the societies of today. pregnancy and accessing safe abortion.

To consult us would make your work more effective and give better results for children.”

It is also important to engage young men ––Young woman, Norway (Greene et al. 2010) (husbands, sexual partners, brothers and “Listen to me, no one else, listen to me. It’s my friends), adults who are responsible for body, listen to me; it’s my life, listen to me.” young women’s well-being, community ––Young person, United Kingdom leaders and providers of health services.

(Participation Works 2008) Through participatory, fact-finding dialogues, participants help us learn about safeabortion barriers and resources for young women. These dialogues can also highlight young women’s needs, experiences and ideas for adults, influence decisionmakers and empower young women to act as change agents. Such dialogues will help achieve the ultimate goal of increasing access to appropriate abortion care for young women who need or want it.

We conduct participatory situation assessments with young women on abortion to improve our knowledge of the realities that they face in their communities. This understanding enables us to design more appropriate and effective programs that meet young women’s needs and desires and are built on meaningful participation. The purpose is to answer these and similar questions: • What are the factors that lead to unwanted pregnancies among young women?

• What barriers to safe abortion do young women face in their community, and which barriers affect their care-seeking behavior the most?

• What are young women’s experiences with abortion? How do these experiences affect them and people who are close to them?

• What are the health-seeking behaviors of young women?

• What factors lead to delays in seeking care for unwanted pregnancies or postabortion complications?

8

Young Women and Abortion: A situation assessment guide

• What opportunities and solutions do young women identify to increase their access to SRHR information and care, including safe abortion?

• What health and community resources exist for young women who need or want safe abortion care?

• How can we most effectively provide information about pregnancy, contraception and safe abortion care to young women?

• What is the role of young men in young women’s unwanted pregnancies and abortions?

• What local support and structures exist to improve young people’s SRHR, including access to safe abortion information and care?

1.2 What is a situation assessment and when do you do it?

A situation assessment is a structured process that helps you to 1) examine multiple factors that affect a known problem and 2) identify resources that can help you find solutions. The assessment takes place at the community level. Needs assessments traditionally focus on service gaps and needs that are not yet met. Situation assessments, on the other hand, help to paint a more comprehensive picture of young women’s realities.

Situation assessments focus on needs, as well as potential resources, assets, structures and opportunities already available in the community. They are a critical first step in your Findings from a situation assessment will help you to identify key allies, as well as the best project design and planning process.

Your project should reflect and respond to your assessment findings, making it more effective. Some examples of potential projects or components of projects include:

information and outreach channels. The findings illustrate community priorities and possibilities and preferred processes for change that the community sees. It is important to note where there are differences in perceptions among groups consulted, and how your resources can be used best.

• Strengthening the quality of and access to appropriate health services for young women • R aising awareness about young women’s sexual and reproductive rights, including the right to safe and legal abortion • E ducating health service managers about policies that create barriers to young women accessing safe abortion • Building the capacity of young women on SRHR and abortion issues • Organizing advocacy to shape public policies that are respectful of the rights and responsive to the needs of young women

Remember!

The aim of a situation assessment is not to change behaviors and transform attitudes. The aim of the assessment is to gather information to plan evidence-based interventions that will change behaviors and transform attitudes.

1. Introduction

9

Structuring a situation assessment depends on time, resources, available data and levels of community interest and involvement. The participatory methods described in this guide are useful for shorter, qualitative, “rapid” situation assessments.

There may be occasions when a situation assessment These participatory methods are based on can provide compelling information. This information might influence a funder to support new program dialogues with key community participants. activities or a policymaker to take action. However, For more information about these methods, often there is no guaranteed funding for follow-up please refer to the Participatory Learning activities before you start your assessment. You may Assessment and Participatory Rapid Appraisal want to conduct an informal risk/benefit analysis to methodologies1 and the resources listed decide whether the benefits of the findings you may get outweigh the cost of conducting the assessment. throughout this guide.

Note! This guide is focused on situation assessments as part of participatory project design. It is not intended for research purposes. If you wish to use any of the information you gather for research publications, additional processes, such as Institutional Review Board (IRB) approval, are required before you start the assessment. These processes are not covered in this guide.

1.3 How do you use this situation assessment guide?

This guide consists of five chapters: Chapter 1: I NTRODUCTION gives you background information about situation assessments, and what the guide includes.

Chapter 2: PLANNING A SITUATION ASSESSMENT tells you how to plan and focus your assessment, and how to gather data that will help you do this.

Chapter 3: IMPLEMENTING A SITUATION ASSESSMENT gives you tips for facilitating assessment methods and sessions with young and adult participants.

Chapter 4: USING THE SITUATION ASSESSMENT METHODS introduces seven assessment methods, with instructions for their use and examples of how to use them with different participant groups.

Chapter 5: FINALIZING A SITUATION ASSESSMENT tells you how to compile, analyze and apply the data that you’ve collected for decision-making and planning purposes.

eg

The guide is structured around real examples from pilot situation assessments carried out by Ipas programs in Nepal, Central America, Nigeria and South Africa. It takes you through the steps of planning, conducting and analyzing findings from situation assessments executed in communities in each of these countries.

Whenever you see this symbol, you’ll know that we’re giving you real examples from our pilot situation assessments in Nepal, Nicaragua, Nigeria and South Africa.

At the end of the guide you’ll also find Appendix A: A situation assessment in ‘Tuva’ which presents a complete, fictional situation assessment from which you can draw information and inspiration.

10

1. PLA and PRA are qualitative research methods that engage community members as partners to help us understand social systems, values and relationships. They originated in rural development but have been adapted for use in urban and peri-urban areas.

Young Women and Abortion: A situation assessment guide

1.4 What assessment methods does this guide include?

The guide shows you how to use seven different methods (see List 1 below and Chapter 4). We recommend using these assessment methods because they engage multiple stakeholders in identifying problems, proposing solutions, making decisions and taking action. They help to ensure the inclusion of all voices. This includes youth voices often overlooked or silenced in conversations about abortion issues. When community members, including youth, articulate their needs, a sense of ownership of future interventions is often greatly increased.

The methods in this guide are intended to be used within peer groups.

Individuals are more likely to speak openly about sensitive issues within the safety of peer groups. Participatory dialogues can also work well with mixed stakeholder groups when participants have an established history of trust, respect and open communication. For example, if a group of peer educators has collaborated with local community health workers for a long time, they could potentially participate in the same focus group. However, in general, dialogues should be held separately with different stakeholders and community members.

List 1 Method

Applicable participant groups

Focus group discussion

Any

In-depth interview

Any, including young women who have had abortions

Reproductive health life line

Women who have been pregnant

Social network circle

Women, particularly young women who have had abortions

Resource mapping

Any

Situational drawing

Any

Attitude assessment

Any, particularly providers and adult stakeholders

If you want to talk specifically to young women who have had abortions, consider methods in which the facilitator meets each young woman individually and privately in a safe space (see In-depth interview and Social network circle). The facilitator should be well-trained and experienced in facilitating conversations with young people on SRHR-related topics. The conversation may raise emotional reactions in participants.

Facilitators should be prepared with a list of community resources and referrals.

Okay, what’s next?

Let’s learn how to plan for a situation assessment!

1. Introduction

11

1.5 References Bremner, Jason, Carl Haub, Marlene Lee, Mark Mather and Eric Zuehlke.

2009. World Population Highlights: Key Findings from PRB’s 2009 World Population Data Sheet. Population Bulletin 64 (3). Washington, DC: PRB. Cook, Rebecca and Bernard Dickens. 2000. Recognizing adolescents’ ‘evolving capacities’ to exercise choice in reproductive healthcare.

International Journal of Gynecology & Obstetrics. 70: 13-21.

Greene, Margaret E., Laura Cardinal and Eve Goldstein-Siegel. 2010. Girls Speak: A New Voice in Global Development. Washington, DC: International Center for Research on Women.

Participation Works. 2008. Top tips for participation: What disabled young people want. London: Participation Works.

Plan. 2007. Because I am a Girl: The State of the World’s Girls 2007.

London: Plan.

Population Reference Bureau. 2006. The World’s Youth 2006 Data Sheet.

Washington, DC: PRB/BRIDGE. Olukoya, A.A., A. Kaya, B.J. Ferguson and C. AbouZahr. 2001. Unsafe abortion in adolescents. International Journal of Gynecology & Obstetrics.

75: 137-47.

Rowbottom, Sara. 2007. Giving girls today and tomorrow: Breaking the cycle of adolescent pregnancy. New York: UNFPA. Save the Children. 2008. Partnership-Defined Quality for Youth: A Process Manual for Improving Reproductive Health Services through Youth-Provider Collaboration. Westport, CT: Save the Children.

Turner, Katherine L., Evelina Borjesson, Amanda Huber, Cansas Mulligan.

2011. Abortion Care for Young Women: A training toolkit. Chapel Hill, NC: Ipas.

Youth Coalition for Sexual and Reproductive Health and Rights. 2009.

Meaningful Youth Participation: What it actually means for you, your work and your organization. Ottawa: Youth Coalition.

World Health Organization (WHO). 2004. Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000, 4th edition. Geneva: WHO. World Health Organization (WHO), Commonwealth Medical Association Trust and UNICEF. 2006. Orientation Programme on Adolescent Health for Health-care Providers. Geneva: WHO.

12

Young Women and Abortion: A situation assessment guide

2. PLANNING A SITUATION ASSESSMENT Throughout this chapter you will learn how to plan a situation assessment, including defining learning objectives and gathering background data from different sources that will create the foundation of the assessment.

This will allow you to move forward with selecting assessment sites and participants. Based on the resources available and the unique characteristics of participants, you will then be able to select the methods to be used in the assessment.

2.1 Defining learning objectives A learning objective is what you hope to learn from conducting your assessment. Having a clear understanding of your learning objective(s) helps you focus assessment activities on the right people, places and questions.

You may have just one learning objective or you may have several within a broader goal. Learning objectives also can have varying degrees of specificity.

A more specific objective will support more targeted participant questions.

After you’ve clarified your learning objectives, it is helpful to prioritize them. Both time and resource restrictions may require you to limit what you can accomplish during your assessment. To see how to do this, refer to the goal and learning objectives our Ipas Nepal team used. eg

Defining and prioritizing your learning objective(s) first will help you prepare the rest of the situation assessment and to design or adapt the questions you’ll ask when using the assessment methods.

Ipas Nepal identified this goal and these learning objectives: Goal: Gather information about young women’s experiences with unsafe abortion in Nepal in order to design interventions to decrease abortionrelated mortality and morbidity among young women.

Learning Objectives: 1. Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

2. Find out where young women obtain sexual and reproductive health care and what services are available.

3. Learn where and how young women obtain abortions and whether they are unsafe.

4. Learn what social support mechanisms young women have and use for seeking abortions.

5. Learn where young men get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

6. Learn how sexually active young men feel about pregnancy and unsafe abortion.

7. Learn how providers feel about laws that limit the availability of legal abortion and about the risks for young women who resort to unsafe abortion.

2. Planning a situation assessment

13

8. Learn how other influential adults feel about young women’s sexuality, sexual and reproductive health, and abortion.

Prioritized Learning Objectives: Most important: 1. Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

2. Learn where and how young women obtain abortions, and whether they are unsafe.

3. Find out where young women obtain sexual and reproductive health care and what services are available.

4. Learn how providers feel about laws that limit the availability of legal abortion and about the risks for young women who resort to unsafe abortion.

Important learning objectives if resources allow: 5. Learn what social support mechanisms young women have and use for seeking abortions.

6. Learn where young men get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

7. Learn how sexually active young men feel about pregnancy and unsafe abortion.

8. Learn how other influential adults feel about young women’s sexuality, sexual and reproductive health, and abortion.

2.2 Gathering demographic and epidemiological data It can be useful to gather quantitative data described in the table below as you prepare for the assessment. Reviewing contextual data can help identify important knowledge gaps you will want to address during your assessment. All data indicated on pages 16 and 17 are recommended.

However, you should select only those data sets that are relevant to your specific learning objectives. Whenever possible, aim to disaggregate all data by sex and age, and if Adolescence is a developmental process and appropriate in your setting, marital status. transitional stage in life. Since the needs and capacities of adolescents vary, it is also useful to

disaggregate data by sub-groups. Sub-groups might Demographic and population data provide include ages: 10 – 14, 15 – 19, and 20 – 24 years. a broad overview of the populations and In some contexts, it is also important to separate subpopulations with whom you will be between married and unmarried young women. working. When reviewing this type of data, it is important to pay attention to information that may influence your program needs. For example, it may be helpful to know the most densely populated areas in order to improve your program’s coverage.

14

Young Women and Abortion: A situation assessment guide

Epidemiological data looks at trends over time, particularly how these trends affect, or are affected by, specific variables. Health facility data, for example, disaggregated by sex and age, can be very helpful. Health facility data may: 1) show whose needs for abortion services are and are not being met, 2) pinpoint high incidences of postabortion complications and 3) give decisionmakers data they can use to justify changing policies or laws. The Pathfinder International Focus on Young Adults Series, Workbook 1: Planning for an Assessment and Collecting Data contains useful information for health facility data review. (See Chapter 2, References)

When looking at trends over time, it is important to keep in mind significant events and external variables that may have affected the area. For example, increases in the number of abortions reported at health facilities may not necessarily reflect an actual increase in the incidence of abortion. Changes in regulations and abortionrelated laws are known to influence how abortion data is collected. This may in turn cause a false increase in the number of abortions formally recorded.

A lot of this data can be found online or in demographic and health surveys (DHS). Useful websites include: www.measuredhs.com and http:// www.who.int/whosis/en/index.html Both sites can help you build statistical reports.

Many Ministries of Health also have websites with similar information. For policies, www.youth-policy. com may be particularly helpful.

2. Planning a situation assessment

15

Types of data

Possible sources of data

Demographic and population data Total population

Census data

Population of adolescents and young people (10 – 24 years)

Census data, demographic and health surveys

Total fertility rate among adolescents (10 – 19 years) and women 20 – 24 years old

Vital statistics records

Most dense population areas

Census maps

Epidemiological data Age in relation to onset of sexual activity

Anthropological articles, peer reviewed journal articles

Age of young women at marriage

National census, youth national surveys, anthropological and sociological studies, peer reviewed journal articles, and research monographs

Age at first pregnancy or first labor and delivery

Patient records, clinic data, national reproductive health surveys, national health system data, health insurance databases, peer reviewed journal articles

Available sexuality education

Education ministry, contraception data, schools

Incidence of sexual violence

Clinic data, national reproductive health surveys, national health system data, health insurance databases

Rates of contraception usage by age

Clinic data, national reproductive health surveys, national health system data, health insurance databases, peer reviewed journal articles

Rates of unmet contraceptive need by age

Clinic data, national reproductive health surveys, national health system data, health insurance databases, peer reviewed journal articles

Incidence of childbirth-related complications

Patient records, clinic data, national reproductive health surveys, national health system data, health insurance databases

Incidence of abortion

Clinic data, national reproductive health surveys, national health system data, health insurance databases, peer reviewed journal articles

Incidence of abortion complications and outcomes

Hospital/ health ministry data

Population groups with highest abortion or abortion complication incidence

Hospital/health ministry data

Incidence of postabortion contraceptive counseling

Hospital/contraception data

Number of hospital admissions related to abortion, by age of the woman

Clinic data, national reproductive health surveys, national health system data , health insurance databases

Percentage of abortion-related hospital admission of the total of reproductive health-related admissions

Clinic data, national reproductive health surveys, national health system data , health insurance databases

Age, number and location of patients in relation to health services

Environmental scan

16

Young Women and Abortion: A situation assessment guide

Social and environmental data Indications for legal abortion, and specific policies affecting minors and young women (such as parental or spousal consent)

International agreements, conventions and treaties (which the country has signed or ratified) International court cases related to reproductive health, maternal mortality and abortion Country constitutions Federal/state laws such as: Abortion laws Infant and adolescent laws Health laws Youth laws Court decisions Penal codes Ministry of Health norms and guidelines

Government, public or private efforts already underway in the community to address the situation, and how well they are working

Environmental scans, other situation assessments

Existing human resources to help improve situation and services (providers, counselors, lawyers, peer educators, judges, politicians, etc.)

Conversations with advocates, reports

Attitude and skill level of providers specific to serving young women

Provider surveys, client surveys

Local infrastructure and technical capacity to respond to needs (# and location of abortion service facilities, affordability of services, privacy and confidentiality of services, # and location of counselors, # and location of contraception dispensing sites, # and location of sexuality and contraceptive educators)

Environmental scans, other situation assessments Health ministry reports and plans Public budgets

It can be difficult to obtain valid information about sexual behaviors like age of sexual debut, number and type of sexual partners, or sexual practices.

You’re more likely to get this information from discussions or interviews with young people who trust the facilitators. Asking young people to talk about their friends’ behaviors can also help increase the validity of this information; people may be more honest about what their friends are doing than about what they are doing.

2. Planning a situation assessment

17

2.3 Selecting situation assessment sites The assessment site(s) you select will influence your assessment findings and thereby your program design. Sites selected, if possible, should be representative of various district and national level characteristics. It is not easy to find a community that is truly representative of other communities in the same district or country. Every community (even within the same geographic area) is different; they are made up of and affected by many variables.

Neighboring communities that seem very similar may have significant sociocultural If you expect to implement your project in more than or economic differences. Thus, it is best to one community, ideally you will conduct assessments select an assessment site that is likely to in at least two different communities within your intended intervention area to capture any become part of your intervention area after differences that may exist. If significant differences the assessment. This will ensure that the exist between the communities, you can use this information gathered through the assessment information to design appropriate, communitywill be most useful when designing your specific project interventions. intervention.

When selecting a potential assessment site you might consider: • Demographic, epidemiological and social and environmental data (See Section 2.2) • Gender and age structure of local population • Socioeconomic status of the community • Political/administrative structure of the community • Local traditions affecting women, particularly young women • Youth-, women- or reproductive health organizations working in the area • Possible allies/partners in the area (including community leaders, village council, etc.)

• Closest doctors, hospitals, clinics and other community referral services that, for example, offer services to survivors of sexual or gender-based violence • R eproductive health services currently being provided • Transportation and communications available and usable Donors, partners and other stakeholders often influence the selection of assessment sites. You may also know where there is need for an intervention; for example, in areas with high maternal mortality and deaths from unsafe abortion. It is important to maintain dialogue with donors, partners and stakeholders in order to have both community and financial support to design and implement your situation assessment and subsequent intervention.

Prior to visiting a potential assessment site we recommend preparing the following information: 18

Before you make your final selection of an assessment site, it is recommended that you visit that site. Visiting a site will help you become more familiar with its context and setting within a larger region. It can also help you gather support and endorsement from community leaders and identify partners (see Section 2.4), and ensure that your assessment and future intervention will not duplicate the efforts of other organizations. Visiting a site before your assessment is also necessary when you want to involve local community members in your assessment team. Only by visiting a community can you begin to identify community members who have the appropriate background and knowledge to effectively co-facilitate a situation assessment (see Section 3.3 to learn about effective facilitation).

Young Women and Abortion: A situation assessment guide

• An overview of the project • A summary of ethical standards for the assessment (See Section 3.1) • Task description for facilitators and participants • Ideal characteristics of facilitators • An activities schedule, including a timeline for conducting the assessment After you’ve made site selections, record your rationales and underlying assumptions as indicated in the example from Ipas South Africa below. eg

Ipas South Africa chose two assessment sites: Assessment sites

Rationale

Assumptions

Two sites in Mogale City, situated in the Western part of the Gauteng Province: Kagiso, a periurban area, and Tarlton, a rural area within the city municipality.

According to the Community Survey 2007 from Statistics South Africa, Mogale City has a population of 319,614 with a large number of young people. There are few health service facilities and it is thought that access to SRH services and safe abortion is limited, particularly for young people. Mogale City has put in place a maternal health programme that aims to educate and support women in the following areas: 1) The prevention of gender-based violence, 2) Cervical cancer, 3) Mother-to-child transmission (PMTCT); 4)Teenage pregnancy and 5) Safe abortion services. (Community Survey, 2007). The assessment will help provide information on how this program is working and addressing the needs and concerns of young people.

By choosing peri-urban and rural areas, information gathered during the assessment will help program planners understand the possibly divergent needs of people living in these two areas.

Both sites are fairly representative of urban and rural areas in other parts of the country, and will likely highlight service delivery discrepancies that are commonly experienced by women in other urban and rural parts of the country.

A local NGO partner working with youth is active in these sites and will be able to help in the assessment process, such as finding youth participants, contacting service providers, etc.

Sites are easily accessible from Ipas South Africa offices to allow close follow-up and monitoring of the assessment process.

2.4 Gaining community endorsement and support An endorsement of your assessment by community leaders and/or partners will help open doors to the information and participants you seek. Community leaders can, for example, assist you in establishing trust and credibility with community groups, identifying appropriate participants and suggesting good meeting places. You’ll want to tell community leaders what information you hope to gather, how you intend to use it and what your expected timeframe is.

2. Planning a situation assessment

If you think community leaders might be sensitive about discussing sexuality or abortion, you may want to use more general language to explain your purpose. For example, you may say that you are assessing the situation of young women in terms of health and relationships. Use your best judgment. If you find this helpful in the local context, it could be beneficial to structure your intervention in a similar way.

19

A well-established community or youth organization can be a valuable assessment partner. Working with a partner can be especially helpful if you’re expanding your work to new locations. A local partner can give you important information about the contexts and behaviors of young people in the community you are assessing. In particular, you may want to consider whether any of the following groups could be prospective assessment partners: • Youth organizations or networks • Groups that provide health or life skills education to youth • Students’ associations or school clubs • Youth ministries • Youth sports programs • Health clinics with youth services or programs • HIV prevention and treatment programs • Juvenile justice programs (to reach youth in prison) While considering a potential partner, respect the organization’s interests, abilities and limitations, as well as your own.

Meaningful youth participation and/or community involvement is proven to have many positive impacts. But it should be weighed against available resources and need for capacity-building, financial or other forms of support. Remember that a partner’s capacity can be beneficial for postassessment interventions too.

If you have not been able to secure funds for post-assessment interventions, there are smaller, cost-effective ways to show appreciation to the community once you’ve completed the assessment. For example, you can offer informal educational sessions immediately following assessment methods for interested participants, or share resources you or others have developed that can help the community.

Young people who live in the assessment community can be invaluable partners in preparing and implementing an assessment. If you can include young people during your assessment without compromising your methods or findings, do so. This provides good opportunities for them to develop and use skills, and may put their peers at ease. They are also essential stakeholders in post-assessment interventions. Young people can: • Share their experiences • Provide helpful suggestions about how and where to find and talk to other youth • Provide inputs on assessment design • Help you facilitate assessment activities • Analyze assessment findings • Contribute to the design, implementation and evaluation of post-assessment projects • Create change in their communities

Remember!

The primary purpose of the situation assessment is to learn about the local context. Never promise post-assessment interventions unless you can commit and have funds for them.

20

Young Women and Abortion: A situation assessment guide

eg

Ipas Nepal identified two important partners for their assessment in Kathmandu Valley: Partner

Rationale

Society for Local Integrated Development, Nepal (SOLID Nepal)

SOLID has experience with adolescent sexual and reproductive health research and using participatory methods. It is a well-established organization, and the staff has ties to the local community.

Bhaktapur Youth Information Forum (BYIF)

BYIF is a local youth-led network with experience conducting SRHR-related peer outreach. They understand the topics well and know how to reach youth effectively. Together the two partners complement Ipas Nepal and make a strong assessment team.

2.5 Identifying effective facilitators Facilitators play a major role in situation assessments. They are part of your assessment team. You are likely to need more than one facilitator. One facilitator may not be able to effectively facilitate many different methods with different participant groups. Generally, it’s preferable for women to facilitate groups with women, and for men to facilitate groups with men. If you have a mixed participant group, it’s preferable to have one male and one female facilitator.

Facilitators’ close interactions with participants greatly influence the quality of the information received. Facilitators can have both a positive and negative influence on the assessment process. The wrong facilitator can alienate participants and undermine assessment findings. However, a good facilitator can relate to participants, making them feel comfortable to share their experiences and insights. Effective facilitators have: Connection to the local setting and assessment population: By living in the area or through other personal experiences, the facilitator is aware of sociocultural issues specific to the assessment setting and population.

She/he is trusted by peers and community leaders and is involved at the community level.

Experience in participatory research: She/he has experience facilitating participatory methods and understands the value of participant-oriented programming and research.

Open-minded and non-judgmental attitude: She/he makes participants feel comfortable, and creates a safe and respectful environment for dialogue. The facilitator affirms participants’ experiences, without judgment, and maintains privacy and confidentiality.

Background in SRHR: She/he is knowledgeable about sexual and reproductive rights, gender issues, healthy relationships, reproductive anatomy and functions, contraception, pregnancy, prenatal care and sexually transmitted infections, including HIV/AIDS. nowledge of abortion issues: She/ K he understands abortion in the context of human rights, as well as the local setting, safe abortion methods, and postabortion care.

2. Planning a situation assessment

Always meet facilitators in person before making a final selection. Meeting them in person will help you gain a true understanding of their character and prior experience in these areas.

21

It can be hard to find local facilitators who have all of the characteristics listed above.

Part of your project goal may be to build the capacity of a local partner or young people to facilitate situation assessments. Consider holding a workshop for your assessment team that provides introduction or refreshers to these various skills. A workshop will also promote bonding among assessment team members. On the right is a sample workshop timeline that may be used/ adapted to support facilitators as they prepare to conduct the situation assessment. Some helpful resources can be found at the end of this chapter.

Sample Workshop Timeline Day 1 – Teambuilding exercises, SRHR, and abortion Day 2 – Youth participation, introduction to situation assessments, and basic research skills Days 3 and 4 – Participants practice facilitating the seven assessment methods, and give each other feedback Day 5 – Action planning (Planning the actual assessment you are about to do)

Assess your facilitator’s knowledge of SRH and abortion before designing the workshop.

Understanding a facilitator’s previous experience in these areas will help you create appropriate and relevant pre-assessment capacity-building. How long you spend on each topic will be based on your facilitator’s prior knowledge and experience.

22

Young Women and Abortion: A situation assessment guide

2.6 Identifying community participants Participatory assessments rely on people as primary sources of information.

We’ve identified seven key participant groups who are important for a meaningful exploration of young women and abortion. Young women are the experts on their own realities and are the most important participants to engage. Research also shows that the majority of young women consult one or more people about their abortion decisions (Finken 2005). These ‘consultants,’ often mothers, sexual partners, and friends, have the capacity to positively or negatively impact young women’s ability to make and act on their reproductive decisions. It is important to involve them in assessments.

2. Planning a situation assessment

23

1. Young women

Young women are the best experts to describe their experiences and realities.

Cultural constraints may make it difficult for young women to share their experiences. Assessment facilitators must create safe spaces for participation.

Both young women who have experienced abortion and those who have not experienced pregnancy or sought an abortion (but may know peers who have) can share valuable information.

2. Young men

As sexual partners, friends and brothers, young men influence whether young women use contraception. They may also affect their decisions about abortion and access to abortion care. As civic actors, young men can become part of social support networks. It is therefore useful to learn their attitudes about sexual relationships, abortion and early parenting, and ideas for change.

3. Mothers (or mothers-in-law)

Mothers or mothers-in-law are usually in charge of family health matters. They are often caught between the need to uphold family and community values and the desire to protect and support their daughters or daughters-in-law. They may also know the abortion resources in their communities. They may constitute a gateway or a major barrier to the ability of their daughters or daughtersin-law to obtain abortions. Mothers who have undergone difficult abortion experiences are likely to want a better situation for their daughters.

4. Traditional healers (may include community health workers without abortion training)

Research shows that young women often turn to untrained providers or traditional healers for health-care needs, including abortion care (Atuyambe et al. 2009; Collumbien et al. 2011; Webb 2000). Traditional health providers’ experiences are important for gathering information about how young women access abortions where they are legally or otherwise restricted by different barriers. This group may include providers of illegal or unsafe abortions. Questions for this group therefore need to be designed in a way that does not appear to jeopardize their reputations or legal standing.

5. Trained abortion care providers (may include community health workers with abortion training)

Trained abortion providers can provide important information about the state of health system infrastructure, the quality of available services, locations where abortions are performed, service use data for young clients, young women’s options where abortions are legally restricted, and provider attitudes toward abortion for young married and unmarried women.

6. Pharmacists, chemists and drug sellers

This group can provide information about young women’s access to medical abortion drugs,2 how well young women are being counseled about drug use, and how pharmaceutically safe the medicines are. This group may include providers of drugs that are not appropriate for medical abortion. Some drug sellers may provide misoprostol without a prescription or in settings where it’s only approved for non-OB/GYN indications. Questions for this group need to be designed in a way that does not appear to jeopardize their reputations or legal standing.

7. Local community, religious and political leaders

Changes to improve the SRHR of young women are usually more effective and sustainable with the endorsement of community leaders and elders. Such leaders can include opinion leaders such as religious leaders and teachers, as well as local politicians and government personnel. Therefore it is important to obtain their endorsement of your assessment and their knowledge and perspectives about the issue.

2. Medical abortion drugs include mifepristone and misoprostol, or misoprostol only. They may have generic names in your local setting

24

You should always include young women in your situation assessment. For the other participant groups, choose those who are most likely to provide the information you’ve specified in your learning objectives.

Young Women and Abortion: A situation assessment guide

eg

Ipas Nigeria selected the following participant groups: Key Participants

Learning Objectives

Young men

• To understand their level of SRH knowledge • To understand their attitudes towards contraceptive usage • To learn about their attitudes towards abortion and support given to their girlfriends or partners if an unwanted pregnancy occurs

Young women

• To understand their knowledge regarding pregnancy prevention and safe/ unsafe abortion • To find out where they access to SRH services, including safe abortion services • To see what resources they have available to them • To get their opinion concerning what programmatic interventions they feel would be most helpful to increase their knowledge to prevent unwanted pregnancies and increase access to reproductive health services

Traditional birth attendants

• To understand their level of RH knowledge • To understand their perception of teenage pregnancies, abortions • To understand how many of their clients are young women as to know the magnitude of the incidence of unsafe abortion provided by TBAs

Older women

• To learn about what level of support young women have from their communities • To understand common RH events experienced in their life time • To understand their attitudes towards young women receiving SRH information • To find out what improvements in social support and SRH services and structure they want for their young women

Medical providers

• To find out the comfort level of the providers in providing counseling for modern contraception, sexuality education and safe abortion services • To understand the magnitude of unsafe abortion in their communities and the most common complications young women present with

Abortion seekers (Interviews with young girls who have procured abortion)

2. Planning a situation assessment

• To understand the barriers to procuring services particular to their communities

25

2.7 Selecting assessment methods To choose the most appropriate method(s) to use with each participant group, you may want to consider: The level of facilitation skills each method requires: The assessment team needs to have the level of skill or experience required to facilitate a particular method effectively. This is particularly important when talking to young women who have had abortions or may be experiencing sexual or gender-based violence.

Learning objectives: Consider what you want to learn most from each group. Refer back to your learning objectives and assess which method(s) can most effectively address the learning objectives you are most interested in for that particular group.

Preferences of and dynamics among participants: You need to know whether participants will be more comfortable with conversational methods like focus group discussions and in-depth interviews, or whether they would prefer to engage in more active processes like drawing. Also take into consideration whether participants prefer group processes or one-on-one conversations. This may depend on gender and power structures in the local setting.

Literacy: As much as possible, match your assessment method to the known literacy level of your participant group. Drawing methods are especially useful for low-literacy groups. You should always try to ensure that facilitators speak local languages, and that participants in one group share the same language. If a community has a large number of languages or dialects this may be difficult. Drawing methods can also be useful in groups of participants who do not share the same first language or dialect.

The legal context: If you are discussing abortion in a context where it is legally restricted, this can create a preference, or necessity, for methods that can be done in private, such as in-depth interviews or social network circles.

Once you have selected participant groups and assessment methods, record what method(s) you will use with each participant group.

26

Young Women and Abortion: A situation assessment guide

eg

Ipas Nepal selected the following assessment methods: Participant Group

Assessment Method(s)

Young women (married and with children)

• Focus group discussion

Groups were divided by ethnicity to respect the local setting and gain different perspectives on SRHR.

• Reproductive health life line

1.

Janajati

2.

Dalit

Young women (unmarried) 1.

Janajati

2.

Dalit

3.

Muslim

• Focus group discussion • Resource mapping • Situational drawing

Young women who have had abortion (if we identify any in the other methods)

• Social network circle

Young men (married and unmarried)

• Focus group discussion

1.

Janajati

2.

Dalit

3.

Muslim

• Resource mapping • Situational drawing

Teachers

• In-depth interview

Service providers

• Attitude assessment

2. Planning a situation assessment

27

2.8 Making an assessment budget Estimating your situation assessment costs will further help you clarify the scope of the assessment. You may limit or increase the number of participant groups or methods. You may reduce or increase the geographical scope of the assessment site or the number of assessment sites. This table includes typical assessment costs. You can modify it to match your needs.

Assessment Cost Description

Estimated expense

Staff or consultants Human resources spent designing assessment and collecting data Human resources spent recording, synthesizing, analyzing data Human resources spent writing reports and findings Subcontracts or grants Financial support to assessment partner(s) Travel Transportation for facilitators and perhaps for participants (vehicle rental and fuel, or bus or train fare) Accommodations for facilitators in the field Meals or per diem for facilitators in the field Conference / meeting Training facilitators in assessment methods Refreshments for participants, especially for longer methods Meeting space for assessment methods and follow-up meetings Childcare arrangements for parenting participants Supplies Paper, pencils, markers and tape for invitations Paper, pencils, markers and tape for implementing methods Notebooks and pens for facilitation team members Flipchart, markers, or computer for data synthesis and analysis Communication Extra cell phone time charges

Okay, now you have the background information you need to plan your assessment! Next, you need to prepare for implementing the assessment.

28

Young Women and Abortion: A situation assessment guide

2.9 References Atuyambe, Lynn, Florence Mirembe, Johansson Annika, Edward K. Kirumira, Elisabeth Faxelid. 2009. Seeking safety and empathy: Adolescent health seeking behavior during pregnancy and early motherhood in central Uganda.

Journal of Adolescence, 32: 781-796. (2009).

Collumbien, M, Mishra, M, and Blackmore C. 2011. “Youth-friendly services in two rural districts of West Bengal and Jharkhand, India: definite progress, a long way to go” in Reproductive Health Matters. 2011; 19 (37):174–83.

Finken, L. L., 2005. The role of consultants in adolescents’ decision making: a focus on abortion decision. Jacobs, J.E. and P.A. Klaczynski. The development of judgment and decision making in children and adolescents.

255-278. Mahwah, NJ: Lawrence Erlbaum Associates Publishers.

Webb, Douglas. 2000. Attitudes to ‘Kaponya Mafumo’: the terminators of pregnancy in urban Zambia. Health Policy and Planning, 15 (2): 186-193.

(2000).

2.10 Resources Participatory assessments: Pathfinder International’s FOCUS on Young Adults series takes you through steps from planning, implementing and analyzing data from participatory assessments. We especially recommend the following resource, which suggests key participant groups and appropriate assessment methods for each: Nelson, Kristin, Laurel MacLaren and Robert Magnani. 2000. FOCUS Tool Series 2: Assessing and Planning for Youth-Friendly Reproductive Health Services, Workbook 1: Planning for an Assessment and Collecting Data.

Washington, DC: Pathfinder International. http://www.pathfind.org/site/PageServer?pagename=Pubs_Focus Young women and abortion: Turner, Katherine L., Evelina Borjesson, Amanda Huber, Cansas Mulligan.

2011. Abortion Care for Young Women: A training toolkit. Chapel Hill, NC: Ipas. http://www.ipas.org/Publications/Abortion_care_for_young_ women_A_training_toolkit.aspx

2. Planning a situation assessment

29

30

Young Women and Abortion: A situation assessment guide

3. I MPLEMENTING A SITUATION ASSESSMENT This chapter reviews important steps and considerations for implementing the assessment. It provides you with information about participants’ rights, and about preparing and facilitating assessment sessions. You will also get tips on how to monitor assessment progress.

3.1 Fulfilling participants’ rights When you implement the assessment, you need to start by considering several rights that participants have. For example, participation must be voluntary and all participants have the right to informed consent. When seeking information from individuals about their personal behaviors, rather than about social or community norms, always give extra consideration to their rights to safety, privacy and confidentiality.

Safety: Sexuality and abortion can be sensitive topics to discuss. Sessions should be conducted in a private venue where the conversation cannot be overheard. In case non-participants interrupt, it is useful to have a cover story ready and agreed upon with the participants. For example, when meeting with a group of young women, you might create a cover story that you are holding a workshop about feminine hygiene management.

Informed Consent: Participation must be voluntary. Make sure pressure from others, such as parents, is not influencing a young person’s decision to participate. Informed consent should be given before any session starts.

It can be written or verbal. Giving informed consent requires that each participant has a basic understanding of: –– The purpose of the assessment –– How information will be collected –– Possible risks and benefits for them by participating –– Voluntary participation –– The option to end participation at any point –– Your efforts taken to ensure privacy and confidentiality –– Primary points of contact for questions and concerns –– If payment for participation will be provided, information about this should be included in the consent form.

Requirements for consent vary depending on the local setting, age of participants and whether you are seeking IRB approval. Sometimes it can be appropriate to obtain verbal consent only (see form on page 33). This helps you avoid documenting participants’ names. In some settings, asking for someone’s signature can create a barrier to participation. When participants are minors, IRBs will often require that parental consent is sought and minors assent to participate. The assessment team should carefully consider this issue before including minors in any situation assessment.

3. Implementing a situation assessment

31

Support: Take steps to ensure that resources are available for participants who share emotional information, e.g. referrals to social services or gender-based violence counselors where available. Women may indicate that they have been victims of domestic or sexual violence, or have experienced unsafe reproductive health or abortion services.

In these situations support the women in seeking help from a trained professional.

32

In communities where abortion is legally restricted, asking young women who have had an abortion to share their experience may pose legal risks for them. Abortion-related stigma often provides additional risk. Be sure that you can guarantee the safety of young women before you ask them to speak with you about abortion. This can also be a challenging and emotional experience for the young woman. Consider other measures to protect her best interests. These may include conducting individual interviews in private, preparing a cover story, having an experienced facilitator, and being ready to provide resources and referrals to community support systems as needed. Respect the young woman’s decision to end the conversation if she says so.

Young Women and Abortion: A situation assessment guide

eg

Example: Oral Consent Form Name of organization: Record name of organization Name of study: Record project name Assessment method: Record assessment method used Name of facilitator: Record name of person facilitating the method Date: Record date Location: Record venue and location Participant/ group number: Record a number for the participant or group that you can refer to. Use this number on all pages of notes that you take.

[Read the following statement to the participant(s):] This (interview) is for a study that is being conducted by (Ipas). The information we gather today will focus on (reproductive health). The (interview) will include questions on (relationships, contraception, abortion and social networks). It will take approximately (45 minutes) to answer the questions. Your participation is voluntary. Some of the questions may be about topics that you find sensitive or hard to talk about. You can refuse to answer any question that you do not want to answer, or stop the (interview) at any time.

For individual methods: No one aside from the facilitator, me, will know that you have participated in this study.

For group methods: Only the facilitator, note taker, and other group participants will know that you have participated in this study. Privacy, confidentiality and trust are very important for everyone who is participating.

Please do not relay any information that other participants share. Although we emphasize confidentiality, it is possible that someone may share or report what you say to someone outside of the group.

Your name will never be recorded, and all notes (if applicable: and tape recordings) will be stored in password-protected electronic files and locked cabinets. Upon completion of the project, all files will be destroyed.

Do you have any questions about your right to consent?

Do you consent to participate in this (interview)?

Thank you. x______________________________________ x_______________ (Signature of facilitator/person obtaining consent) (Date)

3. Implementing a situation assessment

33

3.2 Preparing each session You need to carefully prepare each session that will take place as part of the assessment. These preparations will aid effective facilitation.

Recruit session participants: You should already have identified participant groups for your assessment (see Section 2.5). The next step is to consider how many participants to invite to each session, based on the method, and how and where to recruit them. Think about appropriate ways to approach possible participants while keeping their safety and best interests in mind.

Consider what community resources already exist to help you with this. You can work with youth groups and organizations to help you recruit young people as they will likely know where to find young people where they study, socialize and work—at schools, sports events, churches, youth clubs, movie theatres, cafes and bars, and factories or other workplaces.

How to engage harder-to-reach populations Engaging participants can be difficult in any assessment or project. However, the more sensitive the subject area, the more difficult it can become. This occurs for various reasons, including social expectations, laws which may make certain behaviours ‘illegal,’gender issues, concerns over privacy, confidentiality and personal safety, and level of comfort speaking about the issue. You may use different strategies to engage different participant groups. For example, in some communities you will need the permission of the mother-in-law or husband in order to speak with a young woman.

Young men may be hesitant to participate in discussions regarding reproductive health or abortion. Out of school youth may not gather as frequently as their in-school peers, or in as easily identifiable or accessible locations. It is often helpful to ask members of the group you are trying to reach to assist you in efforts to find and motivate potential participants. When working with harder-to-reach populations, you might consider: • Permissions: Whose permission is required or beneficial to reach your desired stakeholders?

• Motivations: What would motivate community members and young people to engage in this assessment? Consider enlisting the help of peers and group members to find and motivate potential participants.

• Social structure: What societal structures/groups are acting as barriers to youth or community participation? What societal structures/groups can support participation?

• Gender dynamics: What level of autonomy/choice do young women have to participate?

• Security: What safety/security concerns might a participant have? How can you work with different community members to address such concerns?

• Level of comfort: How can you make a participant feel more comfortable talking about sensitive issues? How can you ensure participants will feel safe if they are discussing behaviors considered to be ‘illegal’?

Select venue and time: Plan each session in cooperation with recruited participants to select convenient meeting venues and times for them. The number one priority is to ensure the safety and comfort of the participants.

Look for a venue that is closed to the public, quiet, and has functioning doors and windows that can close or lock. Recognize that privacy and confidentiality may not mean the same to you as to participants, particularly younger participants. Respect and fulfill their needs for privacy and confidentiality. (See Section 3.2) Make sure that the venue is accessible to the participants.

34

Young Women and Abortion: A situation assessment guide

Arrange logistics: Think about whether you will need a table as a drawing surface, or walls to tape drawings on. Think about needs for light, fresh air and toilet facilities. If possible, provide drinking water and light refreshments for your groups. If your participant group includes young mothers, arrange for onsite childcare in advance.

Practice: The more familiar you are with facilitating the assessment methods, the better you can concentrate on information shared during sessions, and ensure that sessions go smoothly.

3.3 Facilitating each session effectively Effective facilitation starts with practice. Facilitators should be very comfortable with the method they are going to facilitate. These are some other things to consider: Start and end on time: Always arrive early for your session to make final preparations and greet early participants. Be prepared for possible delays among participants, and factor in extra time in case the session starts late.

Prevent interruptions: Turn off your cell phone and ask participants to do the same.

Ask participants with laptops to turn them off, too. If you are in a room, you may wish to put a “Do Not Disturb” sign on the door. Make sure that everyone in your group can stay for the entire session (unless they choose to stop their voluntary participation).

Even though you take steps to prevent interruptions, they can happen. Prepare a cover story with participants before you begin your session. Often times this can simply be a different topic of discussion. For example, you can tell the intruder that you are holding an informational session about breastfeeding, menstrual hygiene, or another topic you and the participants believe is appropriate.

Allow plenty of time for participants to reflect and speak: As much as possible, match your pace to the pace of the group. People may be waiting for the oldest person in the group to speak first. Or they may simply want to consider the question carefully before responding. Be patient. If participants seem unwilling to speak, consider if there are any comfort issues with group dynamics, or the topic you are discussing. For example, be sensitive to any resistance your group may have toward the topic of abortion. It is usually wise to open dialogue with related issues, like family health, contraception or pregnancy, which they will be more willing to discuss with you. As you build trust and comfort levels, discern the group’s readiness to address more sensitive topics. You can ask, “Is it okay with you if we talk about (topic) now?” Never force discussion if participants are uncomfortable. reate equal opportunities: Ensure that everyone has an equal C opportunity to participate. There are tactful ways to prevent individuals from dominating sessions. For example, you can say, “Thank you for that comment; now I’d also like to hear what others think,” or, “We’ve heard a lot from some group members; now let’s hear from those who haven’t yet shared their views.” These statements allow you to keep the conversation focused while expressing appreciation for the contributions of talkative participants. During drawing exercises, make sure that each person does his or her own drawing.

3. Implementing a situation assessment

35

Use appropriate language: Make sure your questions and vocabulary reflect your legal context, community norms and participant group. The questions you ask will be different if abortion is legal or legally restricted where you work. Use terms that are locally appropriate for the community (for example, “menstrual regulation” rather than “abortion”) and the participant group (for example, with youth “drop your period” rather than “menstrual regulation”). See more on youth-appropriate language in Section 3.5.

Engage key informants, such as community stakeholders and members of your participant groups, early to understand the local context and the appropriate way to discuss sensitive topics.

You may also choose to begin your discussions by reviewing the different terms and phrases that may arise during the conversation.

Body language is also important. Slightly leaning toward a person, making eye contact (where culturally appropriate to do so) and giving them supportive nods are all ways to encourage someone to keep speaking. Making sounds of agreement (“uhum”) or nodding approvingly can also encourage a participant to elaborate on an answer.

Shifting away from that person, while redirecting your eye contact, indicates that you are interested in hearing other people’s opinions.

Help participants address tensions that may arise: If participants reach an area of disagreement that results in an impasse, invite the group to summarize where they have agreement, and where they have disagreement. Ask if they are willing to acknowledge the areas of disagreement and move on to other topics with you. Document the main opposing points of view. This is important data for your postassessment analysis and planning.

Be prepared to provide information requested: Your objective in each session is to learn rather than educate, but it is wise to arrive prepared for spontaneous requests for information. Participants may ask facilitators questions related to the topics you are discussing. It is recommended that participants’ questions are recorded and then answered at the end of the sessions. You should provide comprehensive and accurate information to the best of your ability, without making any value judgments of participants’ behaviors. If you do not know the answer to a question, tell participants so, and then ask if you can follow up with them later. Make sure to contact participants with a response at a later stage, when the information can be shared with them safely. This demonstrates a mutual information exchange and is a good way to thank the group.

36

Young Women and Abortion: A situation assessment guide

Additional tips for facilitating sessions with young people Be respectful of young people’s contexts and concerns: In communities where young people are routinely devalued, young participants may be skeptical about your genuine interest in what they have to say. As much as possible, familiarize yourself with their contexts and concerns before your session. During the session, accept what they tell you without judgment or contradiction.

Remember that in this context they’re the experts, and you’re there to learn from them.

Make sessions as interactive as possible: Most people don’t like boring lectures, but do enjoy active learning opportunities. Think of ways to make the conversations lively. You can use humor and encouragement, and express enthusiasm, respect and appreciation.

Avoid yes/no questions: Use open-ended questions to help participants open up and to encourage longer answers. Following up key questions with more probing questions can stimulate conversation and help you get the information you are seeking. Ask clarifying questions if something does not make sense to you, but do so in a neutral manner.

Use youth-appropriate language: If possible, find out what local phrases are used by young people to describe sexual activities in the communities you will assess. Use these local phrases in your participatory dialogues with youth. You can ask young participants to tell you such phrases at the beginning of your discussions. Make sure everyone understands words used by the facilitators and by other participants. If there appears to be any confusion, ask people to explain what the word means to them.

Research shows that young people tend to frame their discussions on sex and abortion around sexuality, and not around reproduction. So terms like ‘reproductive health’ may not hold much interest or meaning. Be sure to meet with community partners and young people prior to your assessment to review appropriate vocabulary, or field test all questions. Some examples of words and phrases commonly used by young people are shown here. These examples may not be used by young people in the community you will assess.

Sexual activity: have sex, visit, hook up, do it, get with your girl/boyfriend Unprotected sex: skin to skin contact, doing it without a raincoat Pregnant: in a family way, expecting, incubating Abortion: bring back/drop your period, menstrual regulation

Handling participants’ experiences with sexual violence Facilitators may discover during a session that a young participant is experiencing sexual abuse or violence. It is important that facilitators have experience leading sensitive discussions with young people. Facilitators should know what to do if, during a session, it becomes apparent that a participant has experienced sexual abuse and violence. The facilitator may want to talk with this person privately to find out if there is anyone with whom s/he can safely confide in, and provide referrals to any existing, safe resources. Avoid any action that could place this person at greater risk. At the same time, there may be laws that require you to report known abuse. Prepare carefully for this kind of situation before you facilitate sessions with youth. Your plan should include a list of community resources that may be available to assist the young person. Useful tips about referrals can be found on page 15 of : http://www.who.int/gender/violence/en/womenfirtseng.pdf

3. Implementing a situation assessment

37

3.4 Recording and reviewing information Collect all participants’ materials: Immediately after a session ends, collect all papers on which participants have drawn or written. Identify them by location, venue, participant group number and date.

Write up your reflections: Write up your reflections on the sessions as soon as possible, while information and conversations are fresh in your mind. Capture any thoughts or ideas that occurred to you during the session.

Review official notes: Review notes that the note taker took. These notes should be verbatim notes of participants’ conversations, or participants’ explanations and comments on drawings that they did. Write down any questions that you have and that may need clarification.

Set up a simple record-keeping system: You may want to create a daily form to record all of the sessions that you complete. eg

Ipas Central America used this daily form: Date:______________________________ Session 1

Session 2

Session 3

Assessment method Location Venue Time Facilitators Participant group Number of participants Info/education provided Any follow-up needed Contact information for follow-up Particular challenges Other comments

38

Young Women and Abortion: A situation assessment guide

3.5 Monitoring assessment progress Monitoring during the assessment is a first step of data analysis and synthesis (see Chapter 5). You should monitor the assessment process carefully and at every step. Monitoring can help you determine if any changes are needed in the way you are conducting the assessment. As facilitators become more familiar with the assessment methods, it is helpful to monitor their progress and the areas in which they may improve. Similarly, it is important for facilitators to be observant as they conduct sessions with participants. Some key areas to monitor include: • Facilitator’s skills • Facilitator’s level of comfort conducting assessment methods • Number of participants • Level of comfort among participants • Quality of information gathered (number of topics addressed, etc.)

• Number of referrals for health services and other types of support • Number of interruptions (list reasons for interruptions) • Site security throughout the assessment • Level of confidentiality maintained throughout the entire assessment and immediately after An important way to monitor the assessment progress is through daily “debriefs.” The assessment team should meet at the end of each day to reflect on the day’s sessions and process. Write up notes on all participatory sessions, adding explanatory notes for visual drawings and maps (if you have not already done this). This is especially important when you have more than one set of facilitators or when they are working in different locations. Daily debriefs allow you to: • Share and store all participants’ materials: One team member should collect drawings and notes from all the sessions that day, and keep them together in a safe place.

• Discuss the results of the day’s work.

• Provide feedback to each other on the day’s facilitation processes: Facilitators can learn a lot from each other by sharing experiences, tips and strategies.

• Prepare for the next day’s work.

During these debriefing sessions you may want to reflect on some of the areas you have chosen to monitor. If a particular assessment method isn’t working well, you will want to brainstorm ways to adjust the method more to the local context. For example, you may find that in a group setting young women are less willing to speak about abortion. If this is the case, you will need to consider other methods that may provide more privacy around young women’s experiences with abortion.

Okay, what’s next? Let’s learn how to use the assessment methods!

3. Implementing a situation assessment

39

3.6 Resources Effective facilitation: International HIV/AIDS Alliance. 2001. A Facilitator’s Guide to Participatory Workshops with NGOs/CBOs responding to HIV/AIDS. Brighton, UK: International HIV/AIDS Alliance. http://www.icaso.org/vaccines_toolkit/ subpages/files/English/participatory_workshops_facilitators_guide_eng.pdf.

Working with young people: Lansdown, Gerison. 2005. The Evolving Capacities of the Child. Florence, Italy: UNICEF Innocenti Research Centre. http://www.unicef-irc.org/ publications/pdf/evolving-eng.pdf. See Part 2, Section 2: Approaches to assessing children’s capacities; and Part 2, Section 3: Creating environments to promote, respect and protect children’s evolving capacities.

Family Health International. 2005. Youth Participation Guide: Assessment, Planning and Implementation. Arlington, VA: FHI. http://www.fhi.org/en/ Youth/YouthNet/rhtrainmat/ypguide.

Sexual violence and participant safety: World Health Organization (WHO). 2001. Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence Against Women. Geneva, Switzerland. http://www.who.int/gender/violence/en/womenfirtseng.pdf.

Monitoring and evaluation: Adamchak S, Bond K, MacLaren L, et al. Monitoring and Evaluating Adolescent Reproductive Health Programs. Washington, DC: FOCUS on Young Adults, 2000.

40

Young Women and Abortion: A situation assessment guide

4. U SING THE SITUATION ASSESSMENT METHODS This chapter gives you an introduction to and instructions for seven situation assessment methods. These methods focus on learning participants’ perspectives, attitudes and experiences, and are useful when talking about sensitive subjects such as abortion. It may be useful to use all of these methods when conducting a situation assessment, but it is not necessary to use them all as some methods gather similar information. Time and resources available will also help you decide how many methods to use. It is important to gather information about the same topic from different participant groups to understand divergent perspectives. Furthermore, some methods are better suited to certain topics and participant groups than other methods (see below). It is important that you select methods ahead of time, and adapt and field-test questions based on the local context.

4.1 Focus group discussion What is this method?

A focus group discussion is a group interview used to learn about the attitudes, beliefs and experiences of a specific group of people. It is primarily used to learn about social scenarios and norms, not individual behavior. It is a guided conversation during which the facilitator asks a few key, open-ended questions followed by more specific, probing questions based on participants’ responses.

Focus groups typically include 6 to 12 peers who share a common experience or characteristic (for example, all receive services from the same clinic) and are of a similar age group. It is usually most appropriate to separate women and men. In mixed groups, women may defer to or be overruled by male participants because of gender norms. When possible, we recommend holding at least two focus group discussions about the same topic with two different sets of the same peer group, for comparative purposes.

It may be easier to recruit participants by saying that you wish to learn about the views and experiences of young women with regard to family health, rather than pregnancy and abortion. In situations where parents have concerns about whether this is an appropriate conversation for their daughters, you may want to conduct the reproductive health life line method (Section 4.3) with mothers first, and ask to talk with their daughters afterward.

Focus group discussions typically cover 6 to 12 key topic questions, with probing questions for each and additional questions if time allows. Questions should reflect your learning objectives and the age and experience of your participants. Design or adapt questions accordingly.

Remember! A situation assessment does not only gather information about the needs of a population—it also lets participants voice their ideas and opportunities for change. Your key questions should reflect this.

Your facilitation team should include one facilitator and one note taker. The facilitator guides discussion without influencing or judging responses. The note taker writes down in detail what is said and documents questions that cause discomfort or other noticeable reactions.

4. Using the situation assessment methods

41

© Richard Lord

When do you use this method?

Focus group discussions are useful to produce insights that would be less likely without the interaction found in a group setting. Listening to the experience of others stimulates ideas and memories. It also validates experience that may then be more comfortably shared.

It’s an efficient way to talk with several peers about the same topics at once.

How do you use this method?

Whenever possible, tape-record all discussions to ensure that all information is captured. However, this raises serious privacy and confidentiality issues that will need to be addressed. You can make an agreement to destroy the tapes once they’ve been transcribed, and to destroy the transcription notes once your paper has been written. Discuss with participants beforehand. Do not tape-record sessions unless all participants give informed consent.

Time Ideally, a session should last between 90 to 120 minutes. It can be hard for facilitator, note taker and participants to concentrate for more than 2 hours. If more time is needed, a break should be provided. Refreshments are helpful in keeping energy and participation levels high. Some groups may take more time when responding to these questions. Others may take less. It may be necessary to adjust the number of questions if sessions are taking more than 3 hours with a break halfway through.

Materials • Focus group discussion guide with a list of key questions and possible probing questions • Refreshments • Flip chart and marker • Notebook and pen • Recording device, if sessions will be recorded

42

Make sure you have enough space in your notebook for recording answers to each question. It may be helpful to number each key question so that you know which question answers refer to, or to write down the key question as the facilitator asks it.

Some people prefer to record their notes directly on to a previously printed focus group discussion guide for ease of note taking and organizing data recorded at various sites.

Young Women and Abortion: A situation assessment guide

Preparations • Draw a young woman on a flip chart who resembles young women in the community in which your focus group is taking place.

• Prepare a cover story in case someone interrupts the focus group discussion.

Facilitation instructions • Greet the participants and explain the purpose, topic and length of the focus group discussion. Tell them how the information gathered will be used and protected.

• Reassure the group about the confidentiality of the discussion.

Remind participants that this means both facilitators and participants have to keep each other’s answers confidential. Tell them that in this conversation there are no right and no wrong answers.

• Ask the participants for consent to participate. You can read a verbal consent form aloud (see Section 3.1), or use a written consent form.

Thank participants for being willing to talk to you. If the session is to be recorded, ensure that all participants agree to this before beginning.

• Show the drawing of a young woman who resembles the group you are talking with. Invite the group to give her a typical name for a young woman in their community. Tell participants that instead of using their own names or names of friends in the discussions, they can refer to this young woman. It provides safety for young women to talk in the third person rather than first person about their own experiences.

• Ask participants the first key question.

Depending on their answers, select and ask a few probing questions.

• O nce you feel participants have shared everything they want to share, continue asking the remaining key and probing questions. You can also transition between key questions by asking the group if they are ready for the next question.

Describe the fictitious young woman as someone who would fit into the group with whom you are currently working. You could highlight characteristics such as age, marital status, school status, etc. Use her name through all of the focus group discussions. In some instances it may be preferable to use the phrase “a young woman like you in your community or “another person your age” rather than invent a fictitious person. Follow the lead of your participants.

• A fter you have asked all the key questions, ask the group if there is anything else they would like to share with you that is related to what you’ve been talking about. This gives participants who haven’t talked much a last opportunity to share, and in a context where they don’t have to know the answer to any particular question.

• Answer any questions or provide any information that participants may have requested during the discussions. It is also important to correct any misinformation or misconceptions that participants may have mentioned.

• Thank the group for sharing their experiences and ideas with you.

After the session, you can offer to stay to answer private questions that participants may have. As soon as possible thereafter, review the session notes and write down your own recollection of information and themes that came up during the discussion. (See Section 3.4) 4. Using the situation assessment methods

43

eg

Ipas Nepal used the following key and probing questions in their focus group discussions with young, unmarried women: Key question 1: What type of relationships can a young boy and a young girl have?

Probing question: 1.1

How do you know about these types of relationships?

1.2

Where do you get the information regarding these relationships?

1.3 Do you think that the information you have regarding these relations is correct?

1.4

What more would you want to know?

Key question 2: In your opinion, what do you think about young people having information about the different types of relationships between a young boy and a young girl?

Probing question: 2.1 What resources can provide you with appropriate information regarding these relationships?

2.2

Where and how would you like to get that information?

Key question 3: How could a young girl know whether she is pregnant?

Probing question: 3.1

In what circumstances might a young girl get pregnant?

3.2

How might a young girl avoid getting pregnant?

Key question 4: Where might a young girl access care to prevent pregnancy?

Probing question: 4.1

What type of devices or services might a young girl access there?

4.2

Who might help the young girl access services there?

4.3 Would the young girl feel comfortable accessing care there? If yes, why? If no, why not?

4.4 How could we make the young girl feel more comfortable accessing care there?

Key question 5: If the young girl has an unwanted pregnancy, what are the alternatives for her? What might she do?

Probing question: 5.1 With whom would she be able to share her problems?

5.2 With whom would she learn of the alternatives to having the child?

5.3 Who would decide the best option for her?

5.4 Could the young girl decide for herself what she would do?

44

Young Women and Abortion: A situation assessment guide

5.5 What options could harm the young woman? What kind of harm might they cause?

5.6 What would the man involved in her pregnancy do? What should he do?

Key question 6: If she gives birth, what would happen to the young woman?

Probing question: 6.1 What might her friends and family think if she gives birth at her young age?

6.2 Who will take care of the baby?

6.3 If you were her close friend, what would you think about her?

Key question 7: To access abortion care where might she go? Or where might her family take her?

Probing question: 7.1 Would the young woman feel comfortable going to this/these place/s? If yes, why? If not, why not?

7.2 Do you think the place can maintain privacy? If yes, why? If no, why not?

7.3 Do you think the place offers safe care? If yes, why? If no, why not?

Key question 8: After her abortion how might the young woman feel?

Probing question: 8.1 What problems might she face?

8.2 Would her family tell others about her situation? If yes, what might they say? If not, why would they choose to not share this information?

Key question 9: If she has complications after her abortion what might happen? What would she do?

Probing question: 9.1 With whom might she share this problem? If she does not share it with anyone, why not?

9.2 If her relatives take her to another place, where might they take her?

Key question 10: What changes might she experience after the abortion in her life?

Probing question: 10.1 Would she be happy or sad?

10.2 Would it impact her ability to marry in the future? How? 10.3 Would it impact her ability to become a mother in the future? How? Key question 11: Do you know of any other young women that have faced or are facing this same problem?

4. Using the situation assessment methods

45

Probing question: 11.1 Are there young women in your community facing this problem?

How many do you think?

11.2 Would you help her? What would you do? If you would do nothing, why?

Key question 12: What do you think about young women like you having information and care regarding relationships, sexuality, pregnancy and abortion?

Probing question: 12.1 If yes, what changes are necessary for young women like you to access information in your community? (Ask for examples).

4.2 In-depth interview What is this method?

An in-depth interview is an individual conversation in which an interviewer (facilitator) asks a participant questions in a neutral manner and records the answers. In-depth interviews typically contain a combination of closed (yes/ no) and open-ended questions. As with a focus group, you can ask key questions and follow-up probing questions, and have additional questions to ask if time allows. Make sure your questions match your learning objective(s).

The questions you ask and the way you phrase the questions need to be the same with every participant in order for your data to be comparable. The order of the questions may vary to allow for natural flow of the conversation.

A good interviewer will circle back around to questions that didn’t get asked.

When do you use this method?

In-depth interviews are preferable when you don’t want any aspect of group dynamics (for example, power imbalances) to influence your participants’ responses. They are also preferable when it is difficult to gather a group of participants because of scheduling, distance or other logistical challenges.

Another reason for using in-depth interviews instead of focus group discussions is that it allows highly sensitive topics to be discussed in a confidential setting. © Richard Lord

Keep in mind the different reasons to use in-depth interviews and focus group discussions. Focus group discussions build from participant interactions and focus on societal norms. Interviews, on the other hand, require reflection by an individual about his/her personal experiences. Individual interviews encourage participants to share their experiences while also protecting their privacy. The facilitator and community partners should carefully consider the differences between these two methods and the appropriate times to use each.

46

Young Women and Abortion: A situation assessment guide

How do you use this method?

Time • 45 - 90 minutes for each interview Materials • Interview guide • Notebook and pen ecording device (see tip box above under focus group discussions), if • R desired Preparations • Find an interview location that provides as much privacy and confidentiality as possible and minimizes the risk of having others overhear the interview conversation.

• Prepare a cover story in case someone interrupts your interview.

• Familiarize yourself with the interview questions before you begin to conduct interviews.

• Print out the in-depth interview guide so answers can be recorded directly on to the question guide for each respondent, if desired.

• Label the interviews in a simple way (for example, the order in which interviews occur), with participant number, interview location, venue and date.

As a facilitator you are responsible for creating a safe space that helps participants feel comfortable.

Securing a location in which no one will interrupt the interview is the first step. Other important steps include: finding a room that is quiet; closing the doors and windows; providing comfortable seating; and responding to the special needs of your participant.

Facilitation instructions • Greet the participant and explain the purpose and length of the interview. Tell them how the information will be used and how confidentiality will be protected. Ask the participant for consent to be interviewed. You can read a verbal consent form aloud (see Section 3.1), or use a written consent form. If the session will be recorded, make sure you ask permission from the respondent (see tip box under focus group discussions) before you begin recording.

• Ask the participant the first (key) question. Depending on their answers, you may wish to ask a few probing questions.

• Once you feel the participant has shared everything they want to share, continue asking the remaining questions. You can also transition between questions by asking the participant if s/he is ready for the next question.

• A fter you have asked all the questions, ask the participant if there is anything else s/he would like to share with you. This gives him/her a last opportunity to share information.

• A nswer any questions that arose during the interview process and correct any misinformation that the participant may have mentioned.

4. Using the situation assessment methods

47

• Thank the participant for sharing his/her experiences and ideas with you.

After the session, be prepared to answer any questions the participant may have after the interview. Then read through your notes and add any details that are still fresh in your memory.

During in-depth interviews, ask mostly open-ended questions to elicit more detailed information. Don’t attempt to influence what the participant says. Be aware of any intergenerational power dynamics that might affect the participant’s answers. If a participant decides not to finish the interview, accept the decision and thank the person for the time they’ve spent with you.

How to engage different types of participants Anyone who has conducted in-depth interviews knows that each participant is different. These differences can make interviewing very challenging. In each interview the facilitator must work to understand who the participant is and the best way to engage him/her. Below are some examples of the different types of participants you can expect to encounter: Unresponsive or shy: Some participants are less willing to respond to the questions that you ask. In these situations you can ask the participant to talk about a friend rather than him/herself. Providing examples is also helpful, allowing the individual to relate to an example outside of her own experience. Hypothetical situations are useful. Drawings or photos can also help. Through each of these techniques you may gain insight to the participant’s perspective and decision-making process.

Cannot stop talking: Sometimes participants are too eager to share information.

They may spend too much time on one question or become sidetracked with another topic. In these cases it is best to politely interrupt the participant by looking away or back down at your interview guide. If the participant doesn’t respond to your body language it is appropriate to gently interrupt the person. You might try saying, “Thank you for sharing your thoughts, I would now like to speak about” or, “I apologize for interrupting, but I want to make sure we are able to address some other important questions.”

Frequently sidetracked or avoiding a question: Some questions may be harder to answer than others. When feeling uncomfortable, participants often switch the subject. If you notice a participant is continually avoiding a particular topic or question, think about less confrontational ways to address the issue, such as through examples or drawings. In some cases it is appropriate to ask the participant why he/she does not feel comfortable talking about a particular issue.

48

Young Women and Abortion: A situation assessment guide

eg

Ipas Nepal conducted in-depth interviews with unmarried and married teachers. They used these questions: 1.

How are you doing? Can you tell me a little about your daily life?

2. Have you heard about sexual and reproductive health (SRH)? If yes, from where?

3.

What do you know about SRH?

4.

Do you teach SRH classes in your school?

If yes: 4.1

How comfortable are you teaching topics related to SRH?

4.2 Have you ever received any training to teach SRH? If yes, what kind of the training? How was this training helpful for you and your teaching career?

4.3

What methods do you use to teach students about SRH?

If no: 4.5 Would you like to teach SRH in your school? How comfortable do you think you would be teaching topics related to SRH? 4.6 Would you like to receive any training to teach SRH? If yes, what kind of the training?

5. Where do you think students learn about relationships, sexuality, pregnancy and contraception?

6. What are the major sources of SRH information that students may access? Do these sources provide accurate information?

7. Do you think students should learn about relationships, sexuality, pregnancy, contraception and abortion?

8. How comfortable do you think students feel talking about SRH with teachers?

9. What are the reactions among the students when teachers talk about SRH? 10. Do students talk about their personal relationships and problems with you? If so, what are some examples of the things they talk about?

11. What are the major problems you have seen among young people regarding SRH? 12. What types of contraception have you heard students talk about, or do you think they know about?

13.

Do students have access to contraception? From where?

14.

What would happen if an unmarried student got pregnant?

15.

With whom might the student share her situation?

16. What are her alternatives for dealing with her situation? Who would make the decision regarding her options?

4. Using the situation assessment methods

49

17. Do you know any unmarried student who has become pregnant?

18. Have you ever heard about abortion? What do you consider a safe abortion? What do you consider an unsafe abortion?

19. Have you ever talked about abortion with a student? If yes, can you please share a little about the experience?

20. Do you know of any students who have had abortions? Where do you think a pregnant student may go for abortion?

21. What services or resources do you think your community needs to help young people be informed, have healthy sexual experiences and prevent pregnancies?

22. Do teachers provide any referrals for students to reproductive health services, such as contraception, testing and treatment of sexually transmitted infections, prenatal care or abortion? If yes, where do you refer young women?

4.3 Reproductive health life line What is this method?

This method invites each participant to draw on a chronological life line the critical moments of her life associated with sexuality, and sexual and reproductive health (age at onset of menses, first relationship, marriage, contraceptive use, abortion, childbearing, etc.) and how she felt at these times. Participants also have the opportunity to draw a life line for their daughters. Reproductive health life lines provide a mechanism for women to tell their personal stories and identify their priorities for themselves and their daughters, regardless of literacy levels.

When do you use this method?

Life lines are especially useful with women who have low levels of literacy and for those who are not accustomed to speaking up during group meetings.

They serve to validate the experience of every woman in the participant group and help reduce perceptions of class difference or other social hierarchies, since every woman has a reproductive health history even if the details vary.

In this method we are looking for a comprehensive understanding of a woman’s reproductive health over time, not just abortion.

Mothers are often caught between the pressure to maintain traditional sexual and reproductive health values and practices, and wanting to help and protect their daughters. Using their personal experience can move conversation past obligatory statements about traditional values to their heartfelt feelings and concerns. Adult women often influence the choices and experiences of younger women and may become strong advocates for their daughters if they can do so without jeopardizing their social status. Working together in a group process is one way for women to build solidarity for challenging traditional norms. Because mothers and mothersin-law may treat the same young women differently, it is generally best not to include them in the same group.

This can also be used as a method for comparing the feelings, attitudes and perspectives of women who have had abortion experiences with women who have not directly experienced abortion.

50

Young Women and Abortion: A situation assessment guide

How do you use this method?

Time • 2 hours Materials • Flip chart (or large paper) and markers, pencils, pens or crayons for participants • Chairs and large tables for drawing on (if possible) • 2 life line templates for each participant, plus 1 for you (the facilitator) • Notebook and pen Preparations • Anticipate the number of participants and specific characteristics of participants. Arrange for additional facilitators or assistant if necessary. For example, facilitators should consider having several assistants present when working with larger groups.

• Draw as many life line templates on flip chart (or large paper) as you anticipate needing.

Facilitation instructions • Greet the participants and explain the purpose and length of the session. Say that you hope to learn about the reproductive health needs of younger women in this community by learning from the experiences of their mothers (or mothers-in-law).

• Tell participants how the information they provide will be used and how confidentiality will be protected. Ask the participants for consent to participate. You can read a verbal consent form aloud (see Section 3.1), or use a written consent form. Thank everyone for participating.

• Explain that this session will be divided into two parts. First, women will draw a life line for themselves. Second, they will draw a life line for their daughters (see tips below for women who don’t have daughters). Reinforce that it is not the quality of drawing that matters, but what each participant wants to include in her drawings.

• Give each participant a life line template and a marker (pencil, pen or crayon). Review the life line template with participants. The template is on the following page.

4. Using the situation assessment methods

51

Age

32

Reproductive health life line Example 1: Template

52

Young Women and Abortion: A situation assessment guide

• Ask participants to identify critical points of their sexual and reproductive health history.

• Ask the women to think about how the felt during each of these events.

• Ask them to record each event on the life line template. For each event, encourage them to mark their age along the age line (horizontal axis), and the emotion they felt during the event on the emotive line (vertical axis). Remember, participants can do this either by drawing or writing.

• Remind participants that they are able to choose what events to include on their own lifeline, and they do not have to include all events they think of unless they want to.

• If participants are unclear about the task, you can draw examples on your paper, such as age at menstruation, first kiss, intercourse, marriage, childbearing, miscarriage or abortion. Make up likely ages for these events. Include abortion as an example if you think this will create safety for participants to do the same. Your life line might look something like this:

Reproductive health life line Example 2: Facilitator’s model

injectable FP - used 3 birth of daughter years, then my usband wanted another son my husband was disappointed

Age

12 13 15 17 19 marriage didn’t want to leave school

23 25

birth of 2nd daughter

32

birth of 3rd daughter

While participants are working, walk around and provide assistance. If women are literate, encourage them to write in a few details about why they had positive or negative feelings at each event. If you have an assistant, ask the assistant to help make notes related to significant events and emotions.

4. Using the situation assessment methods

53

• A llow 20 minutes for women to finish their life lines. Allow them to document their sexual and reproductive health experiences as they define them. Your role as a facilitator is not to edit their drawings. Events may include when they stopped their education, started dating or fell in love, experienced domestic abuse, were unable to get pregnant, found employment while raising children or experienced depression associated with child birth. The final life lines may look like this:

Reproductive health life line Example 3: Participant’s version r more er give bhnead t h g u a d t firs om her hus love fr

Age 10

15

breast enlargement

first mensturation was full of fear, unknown about menstruation

20

2nd daughter but she want son

25

2nd child was also miscarried but she was hospitalized so no more problem as before

30 husband goes to foreign country

first child was miscarried which was a painful and had weakness

• Invite women to share their life lines with the group, or in pairs.

Respect the decision of women who do not wish to share. Allow 20 minutes for sharing.

• Take a few minutes for the group to observe whatever common threads (of education, fertility, marriage, motherhood, contraception, abortion, employment, poverty, domestic violence) have been documented. Invite the group to notice what makes women feel positive. Then invite participants to look at what makes them have negative emotions. In particular, point out where sadness is associated with too many children, birth of daughters, contraceptive failure or lack of contraceptive choices.

• Ask the women to think about what, if anything, they would want to be different in their daughter’s reproductive health life experience. Ask them what they would design for their daughters’ ideal reproductive health Some participants may not have daughters. For experience if they had the power to these participants, ask them to think about how they would have liked to live these moments turn their wishes into reality. differently themselves.

• Hand out new, blank life line templates to participants and invite them to draw their wishes for their daughters on the new, blank template. Allow 15 minutes drawing time.

54

Young Women and Abortion: A situation assessment guide

• Optional: You can ask participants to address specific issues for their daughters (that match your learning objectives). This may include sex education, contraception, prenatal care, safe abortion care. For example, you can encourage participants to consider preferred methods and feelings associated with contraception use or safe abortion.

• Once the participants have finished the reproductive health life lines for their daughters, ask them to compare their own life lines with their daughters’. Ask them to share with the group what they wish to change for their daughters’ lives.

• After all women who want to share their wishes for their daughters have done so, invite the group to identify the 3 or 4 desired changes or differences that occurred most often (This is important information about desired changes and priorities).

• Ask the women what would need to happen for these changes to be possible in their community and record their ideas in your notebook.

• Ask participants if they have anything additional they would like to share about the session.

• Thank everyone.

4.4 Social network circle What is this method?

This method identifies what social support the participant has, or would expect to have, as part of an abortion experience. It asks the participant to identify on a visual chart the people she considers part of her social network. A social network consists of whoever a person identifies to be in it. Commonly this includes members from one’s family, group of friends, community sources (for example church or health program members) and professional connections (for example, fellow students or colleagues). A social network impacts access to information and health care, and can play an important role in one’s sense of satisfaction and fulfillment. Research suggests that strong social networks have a protective effect, and weak social networks have a detrimental effect on health and wellbeing.

A social network changes depending on a person’s situation or needs. It changes based on how stigmatized an issue is in the society. For example, a woman’s social network caring for a newborn is likely to be very different from her social network for abortion. For abortion-related care, the “activation” of the social network is dependent on how the woman decides to disclose her pregnancy status and whom she asks for support.

The woman will choose who to talk to depending on who she feels she can trust and who is able to provide support. The support she needs may include information about The term “social network circle” may not translate options for handling the unwanted pregnancy, in your local assessment setting. Facilitators should information about abortion methods, where consider if an alternative term may be more suitable. to find services, funds for services, company Community partners can also provide insights to the local language and suggest alternative terms before, during and after the procedure, and a if needed. Facilitators should also talk to the safe space to stay during the abortion if it is a participants at the beginning of the session and medical abortion. make sure they fully understand the meaning and purpose of the method.

4. Using the situation assessment methods

55

When do you use this method?

This method can help you identify if and where a young woman has social support for sexual and reproductive health-related needs, particularly abortion, according to the young woman herself. While the method is centered on the individual’s experience, it tells us a lot about the larger social spectrum that surrounds this individual. It is important to recognize that even when a community has formal or informal social support mechanisms, they may not be part of a young woman’s support network if she doesn’t know about them or doesn’t think they would provide her support in case of an unwanted pregnancy. The challenge in this case would be to then design interventions and projects to make the mechanisms more accessible to her, so that she can include them in her immediate social network.

The method does not assess the accuracy of the information the woman might receive from her social network. It does, however, help you learn where social support exists and where it is needed, as well as what type of social support young women prefer using. It is particularly useful with women who have already had an abortion.

How to use this method

This method can be used as a stand-alone method, or as a complement to an in-depth interview.

It should be implemented in a very secure and safe venue for the participant. Because this is a drawing-based method, a cover story may not work if someone were to interrupt the session. You must ensure the privacy and confidentiality of the participant in other ways. For example, it is not recommended to write ‘abortion’ on the diagram.

Time • 60 minutes Materials • Copies of the “Social network circle diagram: Template” (next page) • Pens or pencils • Notebook Preparations • Make copies of the “Social network circle diagram: Template,” two per participant. It may be helpful to have a few extra in case the participant wants to start over. Use the template on the next page.

56

Young Women and Abortion: A situation assessment guide

4. Using the situation assessment methods

HIGH MEDIUM LOW SELF TRUST TRUST TRUST

PROFESSIONAL CONNECTIONS COMMUNITY SOURCES

FAMILY

FRIENDS

Social network circle diagram: Template (use for both Versions 1 and 2)

57

Facilitation instructions • Greet the participant and explain the purpose and length of the session. Tell her how the information will be used and how confidentiality will be protected. Ask the participant for consent.

You can read a verbal consent form aloud (see Section 3.1), or use a written consent form.

• Introduce the participant to the topic of social support. Ask her to brainstorm different types of support she knows of. Summarize that there are various types of support (for example, emotional, financial, and physical).

• Then ask the participant what people provide these types of support.

Summarize that many different people can provide support (for example, mothers, friends, health workers, and colleagues). Take notes of the participant’s answers for both questions.

• Give the participant a copy of the “Social network circle diagram: Template,” and a pen or pencil. On the diagram write, or ask the participant to write, “Version 1” clearly.

• Explain that the diagram represents a circle of support, like you just talked about. Say and show: –– That it has four different categories of people: family, friends, community sources, and professional connections.

–– That the participant sharing her experience is drawn at the center (self).

–– That there are three circles that move away from the center (self).

The circle closest to the participant herself will be used to indicate those people closest to her (for example, her sister or best friend).

The closer to the center the participant puts a person, the more she trusts him or her. The middle and outer circles indicate people who the participant has lower trust for or familiarity with.

• Once the participant has become familiar with the diagram, ask her to think about when she was pregnant and her abortion experience.

If the participant has not been pregnant nor had an abortion, ask her to imagine that she – or someone close to her, for example a sister or friend – has experienced this.

• Inform her that you will ask a set of questions about abortion. Explain that for each question, she will get the opportunity to mark on the diagram the different people in her life who supported her during the abortion experience. If the participant is imaging herself or someone close to her in the situation, ask her to consider the different people in her life whom she thinks would support her/her friend.

It may be difficult for some women to talk about their experience with abortion. Support these women to tell their story in third person.

58

Young Women and Abortion: A situation assessment guide

• Ask the first set of questions (questions 1 – 3): 1. Who did/would you talk to before you decided and had the abortion?

2. Who did/would you talk to during the abortion?

3. Who did/would you talk to after the abortion?

Pause between each question to allow the participant to reflect on the question, and write or draw the relevant people on the diagram. Mark each person with the numbers 1, 2 and/or 3 depending on when she spoke to them (1 = before, 2 = during, 3 = after, the abortion).

Remind her to place each person on the appropriate circle (reflecting the level of trust she has with the person). See “Social network circle diagram: Responses to first set of questions” below for an example.

Social network circle diagram: Responses to first set of questions

FRIENDS

FAMILY

other friend (1)

Aunt

ie (1+

3)

Best friend

(1, 3)

r Si,st2e, 3) (1

SELF

Boy friend (1, 2)

HIGH MEDIUM LOW TRUST TRUST TRUST

acist

rm Pha1) (

COMMUNITY SOURCES • Ask the participant the second set of questions (questions 4 – 6). Ask the questions for each person the participant has placed on the diagram. Remember to take notes, carefully recording whether and what support the participant received from each person.

PROFESSIONAL CONNECTIONS If the young woman does not draw the people that she mentions on the diagram, you may wish to ask some probing questions to encourage her. For example “Where would you place this person on the diagram? (How much do you trust them, feel comfortable sharing this information with them, asking for their support?)” and “Why would you place this person here?”.

4. Did this person support you?

5. If yes, what support did this person give you?

6.

If no, why do you think they did not?

4. Using the situation assessment methods

59

• Ask the participant the third set of questions (questions 7 – 8).

Continue to take notes of everything the participant says.

7. Of the people you have mentioned, who did you feel most supported by?

8. Of the people you have mentioned, who did you feel least supported by?

Alternatively, you can mark the person who the participant felt most supported by with a circle around the person on the diagram. You can mark the person who she felt least supported by with a cross over the person on the diagram.

• Give the participant a new “Social network circle diagram: Template.”

On the diagram write, or ask the participant to write, “Version 2” clearly.

• Explain that for the next set of questions, she will get the opportunity to mark, on the new diagram (version 2), the different people in her life who she would want support from during an abortion experience.

If the participant is imagining someone close to her in the situation, ask her to consider the different people in that person’s life who she thinks they would want support from.

• Ask the participant the final set of questions, and probing questions (questions 9 – 12). Remember to pause between each question to allow her to reflect on the question, and write or draw the relevant people on the new diagram. Following the same format as you did in the first diagram, instruct her to mark each person with the numbers 1, 2 and/or 3 depending on when she would like to speak to the person.

(1 = before, 2 = during, 3 = after, the abortion).

9. Who would you want to talk to before you decided and had the abortion?

10.

Who would you want to talk to during the abortion?

11.

Who would you want to talk to after the abortion?

12. For each person) Why would you have liked to talk to this person? What support would you have liked from this person?

Some young women may say that they would not have liked to talk to or get support from any other people. If this happens, you may want to consider asking a probing question about why or how she thinks those people could have supported her better.

For other young women it may be difficult to consider what they would have liked to be different in their abortion experience. You may have to phrase the questions differently, or repeat them several times. For example: “If it had been possible, who do you wish you could have talked to…?” Remember to record participants’ answers to these questions, too.

60

Young Women and Abortion: A situation assessment guide

• After you have asked all questions and the participant has completed two social network circle diagrams, ask if she has anything else she would like to tell you about her abortion experience.

• Ask her if there is anything she’d like to ask you. Allow time for an informal conversation or educational session if the participant asks questions.

• Thank the participant for sharing her experience and her time.

When looking at the participant’s first diagram (version 1), you should be able to tell how she identifies her current social network. When looking at the participant’s second diagram (version 2), you should be able to tell how she wants her social network to look. Your notes from the session are an important complement to her diagrams and will provide critical details and clarifications. If a participant has not identified community sources that you know are available in the community, you could recommend a follow-up discussion to explore what barriers exist to those sources.

You may also wish to consider intervention activities in a potential future project to connect young women with these potential support mechanisms and make community resources meaningful to them.

Alternative use of the social network circle method If it is appropriate, you can modify this method for use with small groups; for example, as a complement to a focus group discussion. This allows you to gather information from more participants at the same time. It is only recommended to use this method in a small group setting once you are certain all participants respect each other’s privacy and confidentiality, follow group norms, and will feel comfortable discussing abortion together. If you use this method in small groups, only ask questions from a hypothetical perspective (”Imagine that you or someone close to you…”). You will also want to arrange for additional facilitators or assistants so each small group has a facilitator or assistant to sit with participants and help them follow your instructions, complete the diagrams and take notes.

4. Using the situation assessment methods

61

4.5 Resource mapping What is this method?

Resource mapping means drawing a map that shows certain kinds of resources in or near a community. It is a version of community mapping.

When do you use this method?

Resource mapping can help you learn about available reproductive health care information and services, including safe and unsafe abortion, and access points or barriers to such services. It can be integrated with or complemented by larger community mapping. It can be used to identify: • People and places that offer safe abortion information and care and other reproductive health services that are respectful of young people’s rights and responsive to their needs; • Places where young women obtain medical abortion information and drugs; • Places where young women have unsafe abortion services; • Sources of community support for young women in need of safe abortion care; • People and organizations who might prevent young women from using safe abortion care (and where they are located); • Places where people talk/communicate about abortion, or could do so, including websites; • Places where young women spend time and where education about contraception and safe abortion could take place; • B arriers to young women’s access to safe abortion care, including distance, lack of transportation, cost, stigma, legal issues and minority age issues.

How do you use this method?

Time • 90 minutes Materials • Flip chart (or other large papers) for drawing the maps

When you implement the resource mapping method with providers, community health workers and traditional healers, conduct different sessions with each group. Keep in mind that you may be asking people to reveal the fact that they provide abortion care or medications where it is legally restricted or prohibited for them to do so. Reassure participants that no personal information will be associated with the maps that they draw.

• Tape (if you need to tape several papers together) • Markers, pens or crayons of different colors • Notebook Preparations • Design or adapt a set of resource mapping questions that meet your learning objectives.

• Design or adapt a set of follow-up questions that meet your learning objectives.

62

Young Women and Abortion: A situation assessment guide

Facilitator instructions • Greet the participants and explain the purpose and length of the session. Tell them how the information will be used and how confidentiality will be protected. Ask the participants for consent.

You can read a verbal consent form aloud (see Section 3.1), or use a written consent form.

• If the group is larger than 6 participants, divide it into smaller groups (of 2 – 6 people in each). It is difficult for more than 6 people to draw on one map. Provide each small group with a flip chart (or several large papers taped together) and different color markers (or pens or crayons).

• Ask the group to draw the basic outline of the community, including main roads, health facilities, churches, schools or other major landmarks, to serve as points of reference.

• Ask your resource mapping questions, allowing enough time for participants to feel satisfied that they have drawn each answer completely before you move on to the next question.

• After participants have answered the resource mapping questions and made corresponding inputs on their map, you may want to ask some follow-up questions about use of information sources and services, barriers to these, and suggested locations for information sources and services that do not yet exist. Remember to carefully write down participants’ answers to these questions in your assessment notebook.

• Ask if anyone has anything else they would like to tell you about the resource mapping they have just completed.

• After all maps are completed and follow-up questions answered, collect all the maps (and any other papers participants have made drawings or notes on). Write the date, location, venue and participant group number on each map. Remember not to include any participant names on the maps.

At times, the answer about resource location might be “Nowhere. That resource doesn’t exist in this community.” In these instances, participants can write the resource on a corner of the map and then draw a line through what they have written, like this: Contraceptive services for young women.

Alternatively, they can mark a location on the map where they think that resource could realistically and helpfully be located. Ask them to indicate clearly that the service is not yet available at that location.

If you are trying to learn what resources are considered accessible by different groups of young people, you can separate participants by age, marital status, or in- or out-of-school status. This is the preferred method as each group of young people will be best informed about their own peer group. Alternatively you can separate questions by age, marital status, or in- or out-of-school status.

In this case, you would ask participants the same question more than once, but each time you can specify a different category of young people.

• Thank the participants for sharing their knowledge and time.

4. Using the situation assessment methods

63

eg

Ipas Nigeria used the following Resource Mapping Questions: 1. Where do young women/ men get information about reproductive health?

2.

Where do young women/men get reproductive health services?

3. Where do young women/men get information about contraceptive?

4.

Where do young women/men get contraceptives?

Ipas Nigeria asked these Follow-up Questions: 5. When you talk about contraceptives, does this include traditional medicines also? Please describe.

6. Which sources of information do young men prefer? Young women?

Why? 7. Do young men prefer to get services from [Facility A] than [Facility B]?

8. Do young women prefer to get services from [Facility A] than [Facility B]?

4.6 Situational drawing What is this method?

This is a variation of the Participatory Learning Assessment drawing methodology. This method aims to identify important sexual and reproductive health resources available to youth, as well as their levels of trust for these resources. It asks participants to identify and draw resources available within their community. This typically includes social networks such as friends, family or teachers, as well as community health centers, pharmacies and informal medical care providers.

This method is used extensively in the Stepping Stones community mobilization process and provides an understanding of youth’s reproductive health experiences and the ways that they receive information and access resources. References for resources related to the Stepping Stone process can be found in Section 4.8.

When do you use this method?

This method is useful for low-literacy groups, groups of people who do not share a common primary language, and for young people who prefer to be more active during information sharing. The method encourages participants to reflect on their level of comfort when seeking reproductive health services and when speaking within various social networks about their sexual and reproductive health. Through this method, for example, you may learn about common social networks (friends, teachers, etc.) that serve as confidants on issues such as contraception. Similarly, you may also learn about reproductive health resources available to youth in the community.

This method can best be used with youth and with other peer groups that benefit from interactive group sessions. Such groups include adolescent men and women. However, it can also be used with community members and opinion leaders to better understand community perspectives and assumptions when it comes to reproductive health among youth,

64

Young Women and Abortion: A situation assessment guide

particularly when speaking with illiterate groups. Question sets should be modified for relevance to each group.

The information gathered during this exercise with these participant groups can then be used to inform more in-depth analysis of the local context.

For example, results can inform focus group discussion guides and semistructured interviews to further understand key issues.

You can use this method with up to six participants in each group; multiple groups in one session are possible; however, a facilitator or assistant should be available to each group to provide opportunities for everyone to speak.

How to use this method Time • Three hours, which can be broken up into three one-hour sessions Materials • Flip chart (or other large paper), one sheet per question, plus a few additional sheets • Different color markers, pens or crayons • Small pieces of paper for legends for each drawing • Tape for attaching legends to the flip charts Preparations • Design or adapt situational drawing questions. It is recommended to have three sets of questions, with about four to five questions in each set (for a total of 12 – 15 questions).

Facilitation instructions • Greet the participants and explain the purpose and length of the session. Tell them how the information will be used and how confidentiality will be protected. Ask the participants for consent.

You can read a verbal consent form aloud (see Section 3.1), or use a written consent form.

• T ell participants that during this session you will ask them different sets of questions and invite them to draw the answers to each set of questions on one sheet. You may wish to say: “When answering the questions, please think about what is common, or usual, among other people your age in this community. You don’t need to disclose information directly about yourself, rather about people your age in general. I’ll ask you a question, you’ll discuss it with your group members, and then you will draw your answers If you have more than six participants and divide the using symbols. I’ll show you how.”

• If the group is larger than six participants, divide it into smaller groups (of 4 – 6 people in each). It is difficult for more than six people to draw on one flip chart. Provide each group with a flip chart (or several large papers taped together) and different color markers (or pens or crayons).

4. Using the situation assessment methods

group up into many smaller groups, you will need one co-facilitator or assistant for each small group to help manage group dynamics. The co-facilitator for each small group will copy symbols and their meanings onto a legend (a small piece of paper that lists symbols and their meanings). S/he will also attach the legend to each sheet of drawings. If you have many small groups, the method lends itself well to the inclusion of young people in the facilitation team as co-facilitators and assistants.

65

• I nvite the participants to draw a symbol representing their peer group in the middle of the flip chart. Give them time to discuss and agree.

If it is needed, you may wish to demonstrate the use of symbols by drawing a symbol for your own peer group. You or your co-facilitator should copy this symbol on a legend and write the name of the participant group next to it. Please see the example below.

Situational drawing Example 1 • Ask the first set of Situational Drawing Questions. Invite participants to discuss the questions and draw answers to them. Allow approximately 30 minutes for discussing and drawing the answers.

• While participants discuss and draw, confirm that everyone understands the process. Check with your note taker to make sure s/he is writing down the correct information (for example symbols and explanations for the legend, and verbal information shared by participants in their discussions).

LEGEND: Young men out of school.

• Once participants have finished their drawing, ask them to explain the different symbols on it. You may wish to use the questions as a discussion guide. Invite one person to explain the answer to only one question or symbol, to give several participants The drawings capture the “what” but not the the chance to talk.

• A sk if anyone has anything else they would like to tell you about the drawing that they have just completed.

“why.” Both are important. You or your cofacilitator should take notes during the discussion about the drawings to help capture the “why.”

• Collect the drawing (and any other papers participants have made pictures or notes on). Make sure the legend and any accompanying notes are complete and attached to the drawing. Write the date, location, venue and participant group number on the drawing.

Remember not to include any participant names.

• If you are doing several sessions, this is the end of the first session.

Thank the participants for sharing their knowledge and time. Be prepared with information and referrals to any existing sexual and reproductive health resources for young women and men. Remind them of the next session venue and time before they leave.

• If you are continuing onto the second set of questions, give each group a new flip chart. Follow the same facilitation instructions for the second, and any subsequent set of questions, as you did for the first set.

66

Young Women and Abortion: A situation assessment guide

eg

The Ipas team in Nepal conducted situational drawings with young, unmarried women.

They worked with local community partners and leaders to help recruit young, unmarried women. Through this activity, the team wanted to understand how women feel about pregnancy and unsafe abortion.

Set 1 1.

Where do young people like you get information about sex?

2.

Which of these sources do people like you trust most?

3. With whom are people like you most comfortable talking about sex?

4. Where would people like you want to get information about sex from?

5.

At what age do people like you begin sexual relationships?

Situational drawing example: Answers to Set 1 Set 1, Kathmandu

Hospital

age for first sexual intercourse 20 25 25 20 22 18 20 22

Friends Mother

Doctor

sisters book Index most trustable comfortable to take information interested to take information from

Set 2 1. Where do young people like you get information about contraception?

2.

Where do young people like you get contraceptives?

3.

What contraceptives do young people like you know how to use?

4. What contraceptive methods do young people like you use the most?

5. What makes it difficult for young people like you to use contraception?

4. Using the situation assessment methods

67

Situational drawing example: Answers to Set 2 Set 2, Lalitpur contraceptives DEPO Noplant pills condom

clinics Nagarpalika clinic

Barriers to get contraceptives • shyness • society (people talk that before marriage young girl is using contraceptive) • unwanted to use condom by boyfriend • lack of knowledge on contraceptives

Index more preferable contraceptives place to get contraceptives

Rx

Hospital

sisters

medical store

Friends

Set 3 1. How do young people like you feel when a young woman gets pregnant?

2.

How do young people like you feel about being parents?

3. What ways do young people like you know of to end an unwanted pregnancy?

4. How do young people like you feel about young women in your community who choose to end an unwanted pregnancy?

5. How do young men feel about their sexual partner if she chooses to end an unwanted pregnancy?

Situational drawing example: Answers to Set 3 Set 3, Lalitpur

happy woman if she is married

fearful (fear of society, family), guilt of not using condom happy boyfriend (can get married)

sad (if the contraceptive was used no problem would occur)

68

suicide attempt Young Women and Abortion: A situation assessment guide

4.7 Attitude assessment What is this method?

This method is adapted from the exercise “Comfort Continuum” in the Ipas publication, Abortion attitude transformation: A values clarification toolkit for global audiences (Turner and Page 2008). In the assessment context, the method is used to learn what are the values and attitudes of assessment participants. Unlike when it is used in trainings, it is not intended to transform assessment participants’ values and attitudes.

When do you use this method?

You can use this method with any group of stakeholders of abortion issues, such as, for example, providers of safe abortion care, social workers or community health workers. The method encourages participants to reflect on their level of comfort around different aspects of abortion, such as providing abortion and postabortion counseling, or providing services for either married or unmarried young women. It can illustrate stakeholders’ attitudes about the right of young women to safe abortion, and providers’ perceptions of their own skills related to abortion care for young women.

The method is most commonly used with providers of abortion care. However, it can also be used with community members, opinion leaders, and local political and religious leaders as a way of better understanding community norms. The information gathered during this exercise with these participant groups can then be used to inform subsequent intervention activities. For example, results can inform selection of topics for future forums and advocacy events with these opinion leaders to address the barriers young women may face in accessing services that are the result of the attitudes expressed during the attitude assessment activity.

If you do use this method with providers and ask them to consider their own skills, remember that the providers will respond based on their own perceptions. Do not assume that their self-assessment necessarily corresponds to their actual skills or to clients’ perceptions. If you want to gather reliable data about provider knowledge and skill levels as part of your assessment, you may wish to use the Ipas pre-workshop surveys included in Ipas’s Woman-centered abortion care: Trainer’s When you identify provider participants for this manual (Hyman et al. 2005) and Abortion method, you should first identify where young Care for Young Women: A training toolkit women are currently accessing services, and (Turner et al. 2011). where they would like to access services. Many You can use this method with up to 15 participants at a time; however, smaller groups allow more room to move and opportunities for everyone to speak.

4. Using the situation assessment methods

young women prefer to seek abortion care in a neighboring community rather than their own. You can ask a clinic or hospital director to help you contact providers in neighboring communities.

69

How to use this method: Time • 60 minutes Materials • Flip chart or other large paper • Signs that say “Not at all,” “A Little”, and “A Lot” • Tape for taping signs and flip charts on the wall • A venue with enough wall space to tape the three signs, and directly below them three flip charts Preparations • Design or adapt attitude assessment statements (10 – 15 statements).

• Draw the signs “Not at all,” “A Little”, and “A Lot” and the flipcharts (see examples below). Include as many numbers as you have statements.

• Tape the signs and flip charts on the wall. Leave plenty of space between the three options “Not at all,” “A Little”, and “A Lot”.

Preferably you can use the length of the room for this.

• Place a marker near each sign.

Your wall should look like this: Not At All

A Little

A Lot

Statement #

Statement #

Statement #

1.

1.

1.

2.

2.

2.

3.

3.

3.

4.

4.

4.

5.

5.

5.

6.

6.

6.

7.

7.

7.

8.

8.

8.

9.

9.

9.

10.

10.

10.

11.

11.

11.

12.

12.

12.

13.

13.

13.

14.

14.

14.

15.

15.

15.

70

Young Women and Abortion: A situation assessment guide

Facilitator instructions • Greet the participants and explain the purpose and length of the session. Tell them how the information will be used and how confidentiality will be protected. Ask the participants for consent.

You can read a verbal consent form aloud (see Section 3.1), or use a written consent form.

• Tell participants that you are going to read several statements. As you read each statement, you will invite them to stand in front of the sign that best represents their feeling about that particular statement.

• Read the first statement slowly, repeating it as necessary. Encourage participants to be as honest as possible, and invite them to move to the statement that best represents their true feelings toward the statement.

• After all participants have moved to a sign, ask one participant to count the number of people standing with him or her, and to write that number next to Statement #1 on the flip chart. Alternately, you can ask a co-facilitator to track the number of participants for each statement so that you or the group does not have to.

• After the number of participants has been recorded, allow a few minutes for providers to discuss the first statement. You can invite them to share their reasons for where they have chosen to stand.

Write down what the participants discuss.

• O nce the group is ready, ask the second and subsequent statements following the same process as for the first.

• A sk if anyone has any final reflections that they would like to share.

• Ask if anyone has any questions.

• Thank everyone for their participation.

Depending on your statements, participants may ask you to define young women. If this happens, ask how they would define young women and if an age cutoff makes a difference in their answers. For example, if a participant would help a 16-year-old have an abortion but not a 12-year-old, you may wish to ask remaining questions using two age ranges to learn more about where provider comfort levels lie.

4. Using the situation assessment methods

Alternative use of the attitude assessment method Providers are often very busy and it may be hard to find a time suitable for all participants.

This could make them less willing to participate.

If this becomes a problem, you can provide each individual participant with a double-sided worksheet that lists the statements and the three options “Not at all,” “A Little”, and “A Lot.” Providers can fill out the worksheet in their free time or between seeing clients. Then you can collect the worksheets. However, using the method in this way is not recommended as you will not get the peer discussion of the statements, which is often the most informative part. Therefore this alternative is only recommended when it is not possible to gather a group of providers.

71

eg

Ipas Nepal used the following attitude assessment statements: 1. I am comfortable with young married women having access to contraception information and methods.

2. I feel well trained and comfortable providing contraception to young married women.

3. I am comfortable with young unmarried women having access to contraception information and methods.

4. I feel well trained and comfortable providing contraception to young unmarried women.

5. I experience judgment or discrimination as an abortion provider in this community.

6. I feel comfortable providing abortion care to young married women.

7. I feel comfortable providing postabortion care to young married women.

8. I believe that young married women who need abortions should be able to get them without spousal consent.

9. I feel comfortable providing abortion care to young unmarried women.

10. I feel comfortable providing postabortion care to young unmarried women.

11. I believe that young unmarried women who need abortions should be able to get them without parental consent.

12. As a provider, I believe that one of my duties is to be sure that the law is adhered to.

13. I think that providing safe abortion to young women who need it is preferable to their resorting to unsafe abortion.

14. I would like to learn from young women how to provide abortion services that better meet their needs.

Okay, now you know how to use the different situation assessment methods! Let’s move on to how to finalize the assessment.

72

Young Women and Abortion: A situation assessment guide

4.7 Resources Focus group discussion and in-depth interviews International Training and Education Center for Health (I-TECH).

2007. Organizing and conducting focus groups. Seattle, Washington: University of Washington. http://www.go2itech.org/resources/technicalimplementation-guides.

Mack, Natasha, Woodsong, Cynthia, Macqueen, M., Kathleen, Guest, Greg and Namey, Emily. 2005. Qualitative Research Methods: A Data Collector’s Field Guide. Research Triangle Park, NC: Family Health International. We particularly recommend: Module 4, Focus Groups, with tips on taking notes, effective facilitation, and asking probing questions.

Reproductive health life lines Cornwall, Andrea and Alice Welbourn. 2002. Realizing Rights: Transforming Approaches to Sexual and Reproductive Well-Being. London, UK: Zed Books.

Situational Drawing You can learn about the method in the Stepping Stones manual, www. stratshope.org/t-training.htm.

Attitude Assessment Hyman, Alyson G., Teresa McInerney and Katherine Turner. 2005. Womancentered abortion care: Trainer’s manual. Chapel Hill, NC: Ipas.

Turner, Katherine L. and Kimberly Chapman Page. 2008. Abortion attitude transformation: A values clarification toolkit for global audiences. Chapel Hill, NC: Ipas.

Turner, Katherine L., Evelina Borjesson, Amanda Huber and Cansas Mulligan. 2011. Abortion Care for Young Women: A training toolkit.

Chapel Hill, NC: Ipas.

4. Using the situation assessment methods

73

74

Young Women and Abortion: A situation assessment guide

5. F INALIZING A SITUATION ASSESSMENT The process of compiling and analyzing data is a critical part of the situation assessment. It is the unique part that enables you to apply your assessment findings and make an original contribution to the community with which you work. In this chapter you will become familiar with one approach that makes this process manageable. It can help you develop an original and innovative project design based on community experiences and data. If you are already familiar with an alternative process for data compilation and analysis of key findings, you may wish to continue using that.

5.1 Compiling your assessment data Once you have completed the assessment, you need to look at all the data in a systematic way. You need to organize or compile your data before you begin your analysis. Analyzing your data is when you identify categories, patterns and themes, or explore what they mean (see Section 5.2). Combined, data compilation and analysis can take days or weeks. The time required will depend on What do you see? The objective of data compilation whether sessions were recorded and need is to create a comprehensive record of the information gathered throughout the situation to be transcribed before analysis can begin, assessment. The objective is not to quickly dismiss the number of assessment methods used, one piece of information for another that appears the number of participant groups and sites more important. Instead, the assessment team assessed, and the method and depth of should gather and record all data that relate to the learning objectives. analysis planned.

Organize your notes independently before meeting with your facilitation team. Put all your notes and reflections in one place so that it is easier to refer to when meeting with your facilitation team. Your notes and reflections should be organized by sessions.

Gather your facilitation team together, and bring your notes, flip chart paper and markers. Transfer your notes onto flip charts and share them with everyone else.

Review the learning objectives for your assessment. Write each learning objective on a separate sheet of flip chart and tape it to the wall.

Identify which participant groups gave you information related to each learning objective or question. List participant groups linked with each learning objective on appropriate sheets. This helps you know which notes to refer back to during data analysis.

Organize your data in a format that is easy to use. It is best for a facilitator who was present during a session to organize that session’s findings. It is helpful to use visual aids, such as tables and charts, to collate your data. You can make a table for each question or statement, or a table with results from several questions. Place them next to the learning objective they relate to.

5. Finalizing a situation assessment

75

Example: Table with Attitude Assessment data (subset of full table) Statement

No. of provider responses A Lot

A Little

Not At All

I believe that young married women should have access to contraception information and methods.

7

0

0

I believe that young unmarried women should have access to contraception information and methods.

2

1

4

I believe that young unmarried women who need abortions should be able to get them without parental consent.

0

3

4

I would like to learn from young women how to provide abortion services that better meet their needs.

2

4

1

Organize and disseminate compiled data among the assessment team. Once the data has been organized and compiled, the assessment team members should be given a chance to review all the data. The data is now ready to be analyzed.

5.2 Analyzing your assessment data

The variety of, and sometimes conflicting, information provided confirms the value of gathering information from several participant groups. Information provided by only one person is not representative of their larger peer group. And information provided by only one group is never representative of the whole community. Consider the perspectives and needs of people not involved in this assessment. Always remember: adults should never speak on behalf of young people, no matter how well they think they understand them.

Data analysis is where you thoroughly review, interpret and give meaning to your data.

Analyzing data from situation assessments is a relatively subjective process.

Because of this, it is important to assess the same issues with different groups and methods. It is equally important to focus on recording what participants actually said. Below are some steps for analyzing qualitative data and synthesizing key findings.

Code your data. “Data codingâ€? refers to the process by which data is grouped into smaller units of data. Data coding allows us to make sense of and analyze our data. In situation assessments, it helps us generate general theories around our topics of focus. Fortunately you have already created some codes that may apply to your data! Learning objectives are a great example of codes that you may use during the coding process. Within one learning objective, more than one code may exist. Here are some tips on how to code data: • Review all the data gathered from all the different assessment sessions related to a learning objective. Write a list of every possible code that may be important to your study. Make sure to define what each code represents. It is a good idea to create a table with the code name and definition so that multiple coders are all following the same guidelines

76

Young Women and Abortion: A situation assessment guide

• Match all the findings from each assessment session to your codes.

Format the coded information into a user-friendly format such as a spreadsheet. If you prefer not to do this electronically, you can add a new flip chart sheet next to each learning objective.

Computer software packages for coding and analyzing qualitative data can be helpful and timesaving where available and accessible.

Information may be considered a key issue or theme when: 1) several people have mentioned the same issue or perspective, 2) when a piece of information is unique and has never been mentioned previously or 3) it significantly impacts reproductive health and abortion programming. The facilitation team should discuss the rationale for highlighting different key themes. Your team may discover that there are conflicting themes for a learning objective. This is okay and important. Contradictions should be addressed during data analysis. Wherever you have conflicting data, look for obvious differences. For example, providers may have one perspective while unmarried young women have another. Your data review and analysis should accurately reflect the differences and commonalities within the community, without censoring any groups’ perspectives.

Example: Coded data matrix Barriers to accessing safe abortion care among unmarried young women

Types of contraception with which in-school young people are familiar

Strong preference for radio among all young participants

Too expensive

Condoms

Most young participants have access to television

Parental consent required

Contraceptive pills

Fewer young participants have access to Facebook, but those who do use it frequently

Unaware of available services

IUD

Mediums of communication among young people

Look for themes in your data and explore what they mean. Themes are patterns that you observe repeatedly as you review your data summaries. Coding (grouping) the data will enable you to identify recurring themes because you can easily identify and review all the data that are coded similarly. However, you may need to read through the data multiple times to identify all of the possible themes; new coding ideas often emerge as you review the data. Take enough time to make sure you capture everything the data has to tell you.

This is a crucial step in the data analysis process. You want to look for themes and significant findings linked with each learning objective, and those that appear across several learning objectives. Consider different processes, timelines and systems at play. For example, you may recognize that throughout a woman’s reproductive lifeline there are key moments 5. Finalizing a situation assessment

77

for intervention. This timeline is worth noting. Similarly, there may be key people or services that would impact a young woman’s reproductive health and access to safe abortion services. These resources and the processes by which women may access them are important to note.

Designate a note taker to record the discussion among the assessment team members as you review the data. The note taker is responsible for documenting all data highlighted throughout the discussion, as well as other observations, comments and questions raised by assessment team members.

Do not settle on the most obvious theme. Use the resources around you and elicit the help of others. It can be very helpful to talk through a conceptual theme amongst your team.

Here are some themes you can look for in your data: • Recurring perceptions or beliefs • M ain areas of agreement or disagreement between participant groups (particularly between young women and other participant groups) • Information that matched or contradicted your assumptions or expectations (We always go into an assessment with some preconceived notions of what we will learn.)

• Topics or issues about which participants had strong feelings • Issues reported as needing to be addressed urgently • Relationships between young women and other key participants • Needs or wishes for information, education or training • Possible allies or change agents • Readiness for change

Pay special attention to conflicting perspectives or experiences among participant groups, and consider how they may impact your intervention design. For example, providers may tell you a service is available (and you may confirm that it is). But if young women tell you that the service is not accessible to them, it does not matter that it is “available.” The young women’s perceptions to the contrary become a real barrier to seeking care. Similarly, a service may be available, but young people may not use it. You will want to address this in your intervention, perhaps through strengthening ties between young people and the health clinic.

• Ideas for how to bring about change ynthesize the key findings. After the data has been coded and the S major themes have been identified, you need to select themes which are most relevant to your learning objectives. These themes need to be synthesized into key findings which highlight the most important information and results of the assessment. Key findings will be useful to assessment participants and partners, stakeholders and organizations when planning appropriate interventions and projects.

78

Young Women and Abortion: A situation assessment guide

eg

Ipas Nepal found the following key findings based on learning objectives as shown below: The situation assessment revealed that community members and young people understand issues of sex, sexuality, contraception, pregnancy and abortion differently. Young people demand information and services related to their sexual and reproductive life. Other community members are quite reluctant to support young people’s access to such information and services.

For young unmarried women who become pregnant, data shows that they have few options—including marriage if the man is agreeable, unsafe abortion, suicide or disposing of the newborn immediately upon birth: “She might throw her baby [away by] putting it in a disposal box (cardboard box)” (18-year old man, Kathmandu).

Data show that young women and men are familiar with abortion and some possible complications. Unsafe abortion is still prevalent in the assessment community, and young people know less about safe methods of abortion and legal indications. They are not inclined to use safe abortion services because of misconceptions that abortions lead to future infertility.

Young women report that they always worry about being stigmatized and isolated from friends and families if they have an abortion. For the same reason, they would not feel comfortable helping a friend who became pregnant before marriage: “We like to help her but society grades us the same as that girl. That’s why we are scared to help her.” (17-year old woman, Bhaktapur). Findings also suggest that young women do not trust local service providers, as they cannot maintain privacy and confidentiality and often deny safe services to young unmarried women: “Young women must look as if they are already married or bring a man as a husband, otherwise they do not evacuate the womb” (21-year old woman, Kathmandu).

List important information gaps or questions that remained unanswered. Missing data may mean that you need to return and collect more information, or that you need to defer designing some interventions until you have more information to guide you. Information gaps may also result when some community members were unable to participate.

List participants that may not have been adequately represented in the assessment.

Draft a report that details your findings for each learning objective and emphasizes the findings that seem most significant to you. The report should reflect learning objectives, key findings, the codes you grouped data into, and the themes you drew from the data. Be sure to include quotes from discussions and interviews conducted to illustrate findings. The report should also clearly outline recommendations for project design and the interventions you are able to support or implement (see Section 5.3). If you are not prepared for project design and implementation, make an outline of what would be helpful when planning interventions with these communities in the future. See Appendix B for a sample You should always share your analysis results with situational assessment report outline.

assessment participants and partners to give them a final opportunity to verify or correct your findings before you disseminate them or apply them to project design. Asking participants to review your conclusions and recommendations will improve their validity and usefulness.

5. Finalizing a situation assessment

79

5.3 Using your assessment data Once you have analyzed your data, consider what changes and strategies it recommends. If you received funding before your situation assessment, you probably already have an intervention plan in mind. If so, use your data analysis to modify and/or strengthen your original plan. If you conducted your assessment to persuade a funder about a need, use your data analysis to shape your proposed intervention design from the beginning. It may be helpful to prioritize your recommendations in a planning worksheet, like this. eg

Based on their data analysis, Ipas Central America made the following project design recommendations in collaboration with community partners: Summary of recommendations based on key findings: • Sensitize factory owners to create an enabling environment for young people’s access to information and SRH services.

• Train and empower young people through a peer education program to support each other’s access to information and services and to advocate for their sexual and reproductive rights.

•

Build the capacity of and support health care providers to establish and provide appropriate sexual and reproductive services, including quality postabortion care, to young people.

• Engage with pharmacists to improve attitudes concerning young people’s sexuality and access to and use of contraceptives to prevent pregnancy. Build capacity of pharmacists to provide accurate and comprehensive information about contraceptives to young people.

• Conduct sensitization workshops with young men regarding SRH, gender, and rights to address gender inequality and sexual violence issues.

Once you outline key recommendations for a project, you can develop a more complex and detailed results framework such as a logical framework, or whatever framework your donor or organization requires.

Keep in mind that your assessment findings also provide important baseline data to use for monitoring and measuring change over time. You can use them to help structure your evaluation and design indicators.

80

Young Women and Abortion: A situation assessment guide

5.4 Disseminating your assessment findings Develop a presentation summarizing your assessment report.

You may want to include your learning objectives, key findings and recommendations. Using quotes can be a powerful addition to your presentation, but make sure the confidentiality of participants is protected at all times.

Share your assessment findings with stakeholders. You can share the presentation, or parts of it, with the communities who participated in the assessment and stakeholders. You may prefer to share information separately with different stakeholder groups. Discretion and caution should be used when publicly sharing sensitive information provided by participants. Consider whether to share data that only some stakeholders are interested in or have resources to act upon.

Consider developing a dissemination plan prior to your situation assessment. It is helpful to know “how” you will use the information that you gather. And “how” you use this information may extend beyond the design of a future intervention. When engaging key stakeholders and participants, consider how you may support them in the immediate future. For example, informational sheets on SRHR are often useful for participants. Similarly, it may be helpful for community leaders to understand the experiences of young women through narratives and other mediums.

5.5 Maintaining your relationship with assessment partners and community members Through conducting the assessment, you have begun to engage with community members. If a project will follow the assessment, you should continue to collaborate closely with them in intervention design, project implementation and evaluation. In projects meant to serve young people, their meaningful participation is particularly important (see Section 5.6 for some useful resources). If community members and young people cannot partner in or lead your project, you can still invite representatives to form an advisory council. You can hold regular meetings to keep community members informed of your progress and gather their feedback on how to improve the intervention. Keeping the lines of communication open with community members can help you to minimize misunderstandings and keep trust levels high as you create impetus for change.

Remember! Young people know the changes they want and how they can happen. Look for ways to support young people’s meaningful participation. Their participation is important for your intervention, too.

5. Finalizing a situation assessment

81

5.6 Resources Youth participation in project design, implementation and evaluation Austrian, Karen and Dennitah Ghati. 2010. Girl Centered Program Design: A Toolkit to Develop, Strengthen and Expand Adolescent Girls Programs.

Nairobi, Kenya: The Population Council. Available online at: http://www. ungei.org/resources/files/2010PGY_AdolGirlToolkitComplete.pdf Family Health International. 2005. Youth Participation Guide: Assessment, Planning and Implementation Arlington, VA: FHI. http://www.fhi.org/en/ Youth/YouthNet/rhtrainmat/ypguide IPPF. 2004. Setting Standards for Youth Participation: Self-Assessment Guide for Governance and Programmes. London: IPPF. Available online at: http://www.ippf.org/en/Resources/Guides-toolkits/Setting+Standards+for+Y outh+Participation.htm Save the Children. 2008. Partnership-Defined Quality for Youth: A Process Manual for Improving Reproductive Health Services through Youth-Provider Collaboration. Westport, CT: Save the Children. http://resourcecentre. savethechildren.se/content/library/documents/partnership-defined-qualityyouth-process-manual-improving-reproductive-he Turner, Katherine L., Evelina Borjesson, Amanda Huber, Cansas Mulligan.

2011. Abortion Care for Young Women: A training toolkit. Chapel Hill, NC: Ipas. See in particular Module 4. http://www.ipas.org/Publications/Abortion_ care_for_young_women_A_training_toolkit.aspx Youth Coalition for Sexual and Reproductive Health and Rights. 2009.

Meaningful Youth Participation: What it actually means for you, your work and your organization. Ottawa: Youth Coalition. http://www.youthcoalition. org/html/index.php?id_art=231&id_cat=7

Congratulations! Now you know how to plan, implement and finalize a situation assessment.

82

Young Women and Abortion: A situation assessment guide

Appendix A: A situation assessment in ‘Tuva’ In this Appendix you will find an example of how to plan, implement and finalize a situation assessment with young women on abortion. It is based on a fictional assessment, which takes place in “Tuva.” Tuva is a midsize town somewhere in the Global South.

A.1 Defining learning objectives Broad Goal: Gather information about young women’s experiences with unsafe abortion in Tuva in order to design interventions to decrease abortion-related deaths.

Learning Objectives: 1. Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy in Tuva.

2. Find out where young women obtain sexual and reproductive health care in Tuva and what services are available.

3. Learn where and how young women obtain abortions in Tuva, and whether they are unsafe.

4. Learn what social support mechanisms young women have and use for seeking abortions in Tuva.

5. Learn where young men get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy in Tuva.

6. Learn how sexually active young men feel about pregnancy and unsafe abortion.

7. Learn how providers feel about serving young women, the laws that limit the availability of legal abortion, and about the risks for young women who resort to unsafe abortion.

8. Learn how other influential adults feel about young women’s sexuality, sexual and reproductive health, and abortion.

Prioritized Learning Objectives: Most important: 1. Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy in Tuva.

2. Learn where and how young women obtain abortions in Tuva, and whether they are unsafe.

3. Find out where young women obtain sexual and reproductive health care in Tuva and what services are available.

4. Learn how providers feel about providing services to young women, the laws that limit the availability of legal abortion, and about the risks for young women who resort to unsafe abortion.

5. Learn how other influential adults feel about young women’s sexuality, sexual and reproductive health, and abortion.

Appendix A: A situation assessment in ‘Tuva’

83

Important if resources allow: 6. Learn what social support mechanisms young women have and use for seeking abortions in Tuva.

7. Learn where young men get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy in Tuva.

8. Learn how sexually active young men feel about pregnancy and unsafe abortion.

A.2 Selecting situation assessment sites Assessment sites

Rationales

Assumptions

District A (approximately 12 square blocks)

District A has one middle school and one secondary school, so many young people live there

NGO that runs sports clubs will help us recruit participants and schedule sessions at convenient times.

Linking with a popular sports/ life skills program will increase acceptance of our presence.

District C (approximately 20 square blocks)

District C is the poorest part of town, Same as above so young women here may be most vulnerable

A.3 Identifying community partners

84

Partner for Tuva assessment

Rationale

NGO that runs sports and life skills program

The NGO has already recruited many youth participants, both male and female, and can help us connect with them and schedule participatory sessions. In addition, the organization may be addressing sexual and reproductive health issues in its life skills curriculum.

Young Women and Abortion: A situation assessment guide

A.4 Identifying community participants Key Participants

Learning Objectives

Young women who have not had, but are at risk for, unsafe abortion (young women who live in a community where unsafe abortion rates are high)

Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

Young women who have had unsafe abortions

Learn what social support mechanisms young women use when they have abortions.

Find out where young women obtain sexual and reproductive health care and what services are available.

Learn what social support mechanisms young women wish they had in Tuva.

Mothers of young women at risk for unsafe abortion

Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

Learn where and how young women obtain abortions and whether they are unsafe.

Trained providers of legally restricted abortions

Learn how providers feel about laws that limit the availability of abortion and about the risks for young women who decide to resort to unsafe abortion.

Counselors at contraception clinic

Find out where young women obtain sexual and reproductive health care and what services are available.

Coaches from local sports clubs who know youth in Tuva well

Learn where young women and young men get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

(Learn about any behavior change efforts underway as part of the life skills curriculum offered by local sports clubs).

Sexually active young men

Appendix A: A situation assessment in ‘Tuva’

Learn how young men feel about pregnancy and unsafe abortion.

85

A.5 Selecting assessment methods Participant Group

Assessment Method

Young women in-school

Focus group discussion

(two middle school groups and two secondary school groups) Young women who have had abortions

In-depth interview Social network circle

Mothers

Reproductive health life line

Providers of legal abortion

Attitude assessment

Counselors at clinics

Resource mapping

Coaches from local sports club

In-depth interviews

Young men in-school

Situational drawing

(two middle school groups and two secondary school groups)

A.6 Focus group discussion questions Key Question 1: What types of relationships do young women like “Sara” know of?

Probing Questions for Key Question 1: • What does she do if she has questions about relationships? Who does she ask? Where does she go or look for information?

• How reliable and accurate do you think these information sources are?

• Who do you think would be the best person in your community to teach her about these things?

Key Question 2: What do you think about “Sara” being able to get information about relationships?

Probing Questions for Key Question 2: • How could she get this information in a way that is comfortable for her?

• Who would she feel comfortable asking this information?

• Where would she like to be able to find this information?

Tell the group that “Sara” thinks she might be going to have a baby. She doesn’t know what to do. She doesn’t want to have a baby. She wants to stay in school.

Key Question 3: How can “Sara” know if she is pregnant?

Probing questions for Key Question 3: • How might she have gotten pregnant?

86

Young Women and Abortion: A situation assessment guide

• What could have helped her not get pregnant?

• What different ways are there to not get pregnant?

Key Question 4: Where could “Sara” have gotten something that would help her not get pregnant?

Probing Questions for Key Question 4: • What might she get at that place to avoid pregnancy?

• Would “Sara” feel comfortable going to that place? Why or why not?

• What would make her comfortable? What would make her uncomfortable?

• Who might go with her or take her to that place?

Key Question 5: If “Sara” is pregnant, what choices does she have?

Probing Questions for Key Question 5: • Who can she talk with about her situation and her choices?

• Who will help her decide what to do? Will “Sara” decide or will someone else decide for her? Who would that be?

• Do you think she should be able to decide for herself?

• Do you think any of her choices might cause harm to her? If so, what kind of harm?

• What do you think the person will do who was involved in “Sara” getting pregnant?

• What do you think this person should do?

Key Question 6: What will her life be like if she has a baby?

Probing Questions for Key Question 6: • How will her friends feel about her?

• How will her family feel about her?

• Who will help her take care of the baby?

• If “Sara” was your best friend how would you feel about her if she becomes a young mother?

Tell the group that we’re going to think about a different outcome for “Sara.” Say that her mother decided she’s too young to have this baby and secretly took her to someone who could bring back her period.

Note! In Tuva we are using questions 7–11 only if the participants indicate that they have knowledge of and/or experience with abortion services (safe or unsafe) in their community.

Key Question 7: Where did “Sara’s” mother take her?

Probing Questions for Key Question 7: • Did she feel comfortable going to this place/person? If yes, why? If no, why not?

• Did she feel safe going to this place/person? If yes, why? If no, why not?

• What happened to her at this place?

• How did the situation get taken care of?

Appendix A: A situation assessment in ‘Tuva’

87

Key Question 8: How did “Sara” feel afterwards (after the situation was taken care of)?

Probing Questions for Key Question 8: • Was she in pain?

• Was she bleeding?

• Was she afraid?

• Was she happy or sad?

• Did she or her mother tell anyone else what had happened? If yes, who?

Key Question 9: If “Sara” had pain or bleeding afterward that didn’t stop, what would happen to her?

Probing Questions for Key Question 9: • Would her mother take her to another place? If so, where?

• What if she didn’t tell anyone that she was in pain or was bleeding? What would happen?

Why wouldn’t she tell?

Key Question 10: How do you think “Sara” would be changed by having this experience?

Probing Questions for Key Question 10: • Would she be as happy as she was before this happened, or happier, or unhappier? Why? • Would she be worried about people finding out about this experience? Why or why not?

• Would this experience make a difference in her ability to get married to a good husband?

Why or why not?

• Would she be able to have babies in the future? Why or why not?

• Would she want to have babies in the future? Why or why not?

Key Question 11: Do you know anyone who has had an experience like “Sara”s?

• Have you heard of anyone at your school who has had this experience?

• How many people do you know about in Tuva who have had an experience like this?

• What would you do? If you would not help her ,why not?

Key Question 12: What would make it possible for “Sara” to learn about relationships, contraception, pregnancy and abortion in your community?

• What are some examples of the changes that would need to happen in her community to provide young women with this information?

88

Young Women and Abortion: A situation assessment guide

A.7 In-depth interview questions (for sport club coaches) 1. Please describe the sports and life skills program at the school where you are a coach.

2. Please describe your responsibilities as a coach in this program.

3. Does the life skills component of your program address any topics related to sexual and reproductive health? If so, what topics?

4. Does your program focus on changing harmful behaviors among youth? If so, what behaviors do you try to change?

5. As a coach, do you interact with young men, young women, or both?

6. Do the students you interact with confide in you about their personal relationships?

7. Based on your conversations with youth in your program, where do you think male students in your program are learning about sex?

8. Where do you think female students in your program are learning about sex?

9. Where do you think male students are learning about contraception?

10. Where do you think female students are learning about contraception?

11. Do you know of any students in your program who have become pregnant?

12. What support, if any, does your program offer to students who become pregnant?

13. Does your program provide any referrals for students to STI clinics, contraception clinics or other reproductive health services? If so, where do you refer students?

14. What services or resources do you think Tuva needs to help young people to have informed and healthy sexual experiences and prevent pregnancies?

A.8 Resource mapping questions 1. Where do young women get reliable information about sex?

2. Where do young women get contraceptive counseling?

3. Where do young women get contraceptive methods?

4. Where do young women get other reproductive health services? Next to each location, please write the kinds of services available there.

5. Where do young women get help with terminating pregnancies that might threaten their life? (This reflects the legal restrictions in Tuva.)

6. Where do young women get support after pregnancies have been terminated?

Follow-up Questions 7. Which of these reproductive health service facilities are most used by young women?

8. Which are least used by young women?

9. What are the reasons that young women use [Facility A] more than [Facility B]?

Appendix A: A situation assessment in ‘Tuva’

89

A.9 Situational drawing questions Set 1 1.

Where do other people your age get information about sex?

2. Which of these sources do other people your age trust most?

Rank the sources using +, ++, and +++ (with +++ being the most trusted source of information) 3. Who do young people like you prefer talking about sex with?

Circle up to three people you are most comfortable with (e.g. parent, relative, teacher).

Rank the sources using +, ++, and +++ (with +++ being most comfortable) 4.

Where would other people your age prefer to get information about sex?

5.

At what age does sex typically begin for other people your age?

Set 2 1

Where do other people your age get information about contraception?

2.

Where do other people your age obtain contraceptives?

3.

What contraceptive methods do other people your age know how to use?

4.

What contraceptive methods do other people your age prefer to use?

5.

What makes it difficult for other people your age to use contraception?

Set 3 1.

How do other people your age feel when a sexual partner gets pregnant?

2.

How do other people your age feel about being parents at an early age?

3.

What ways do other people your age know to end an unwanted pregnancy?

4. How do other people your age feel about young women in your community who choose to end an unwanted pregnancy?

5. How do other people your age feel about their sexual partners who choose to end an unwanted pregnancy?

90

Young Women and Abortion: A situation assessment guide

A.10 Compiling your assessment data Let’s assume our situation assessment in Tuva is complete. We were unable to locate young women who had undergone unsafe abortions, although in focus group discussions we learned that it does happen. However, we did locate two young women who had undergone abortions at the hospital and were willing to talk with us. We conducted separate in-depth interviews with them, and incorporated social network circles into interviews.

The team in Tuva gathered all the data together from the different assessment methods and then organized them by learning objective. Here is an example of how some of the data might be organized: Understand where young women get information about sex and sexuality, pregnancy, preventing pregnancy and ending unwanted pregnancy.

1. Most female students don’t receive sexuality education at school or at home. The majority would prefer to receive sexuality education at school.

2. Participants didn’t know where students could go if they had an unwanted pregnancy.

3. Female students are often approached by older men in the community for sex.

4. Participants feel sympathy toward unmarried peers who get pregnant and would like the community to have safe, supportive services to help them.

5. The sports/life skills program is run by a faith-based NGO that encourages abstinence.

The curriculum includes anatomical information, but no information about pregnancy prevention or options for unwanted pregnancies. The program provides no sexual or reproductive health referrals for young people.

Learn where and how young women obtain abortions in Tuva, and whether they are unsafe.

1. Participants didn’t know where students could go if they had an unwanted pregnancy.

2. Young women who had abortions at the hospital got support from their mothers, grandmothers, and sometimes from hospital providers. In one case, a nurse was supportive; in the other case, the nurse was judgmental and unkind.

Find out where young women obtain sexual and reproductive health care in Tuva and what services are available.

1. No young women would feel comfortable going to the contraception clinic, since friends of their mothers work there and the waiting room is very public.

2. Apart from the clinic, there is no place for young people to get information about sex, contraception, or pregnancy.

3. Young married women usually come to the clinic for contraception after they’ve had two healthy children including a son, rarely before. Young unmarried women rarely come to the clinic for information about contraception, pregnancy or abortion, but anyone who comes will be seen by a counselor.

5. Counselors identified the hospital as the place to find help for unwanted pregnancies.

None volunteered information about other abortion options in the community, and the question made them uncomfortable.

Learn how providers feel about providing services to young women, the laws that limit the availability of legal abortion, and about the risks for young women who resort to unsafe abortion.

Appendix A: A situation assessment in ‘Tuva’

91

1. Providers agreed that young married women should have access to sexuality and contraceptive education and counseling. They do provide postabortion contraceptive counseling to married women.

2. Providers were divided in their attitudes toward young unmarried women having the same access. Essentially, three said yes, and four said no.

3. The majority of providers felt unsure how to interpret the abortion laws.

4. Two of seven providers expressed interest in learning more about providing safe and appropriate abortion services to young women. They acknowledged the increase in student pregnancies and said “we cannot bury our heads in the sand.”

Learn how other influential adults feel about young women’s sexuality, sexual and reproductive health, and abortion.

1. Coaches believe that middle school female students aren’t yet sexually active. They don’t know who the male middle school students are having sex with. They acknowledge more sexual activity among secondary school male and female youth.

2. For older women and mothers, during their youth, getting married was a socially important and enviable event, more important than schooling. They realize their daughters prefer to delay marriage until they finish school and are mostly supportive.

However, they think this is a main reason why unmarried girls are getting pregnant; if they were still marrying early, pregnancies would happen within the marriage and be smiled upon by the community.

3. Mothers believe that making abortion easier will place their daughters at higher risk for sex before marriage; nevertheless they would still like to see the law changed to allow abortions. Nearly every mother in the group shared a story about someone they knew who had died from an unsafe abortion. None acknowledged personal abortion experience. This implies that abortion carries heavy stigma.

4. Coaches agree that sex education is important for students, but are divided about whether contraceptive counseling should be available. Two believe contraceptive education discourages abstinence. The program director has asked for a conversation with us. We see potential to include contraception education in the program.

We noted that a major data gap in our situation assessment is information about young people who are not in school.

A.11 Analyzing your assessment data Following analysis of the data, let’s assume the following key findings were identified (examples only): 1. Young women would like to receive sex education at school.

2. Young women are not comfortable going to the clinic due to lack of privacy and confidentiality. This is a potential resource not yet being used.

3. Young women are at risk for pregnancy because they lack SRH information and skills to negotiate protected sex with partners.

4. Young women are sympathetic toward peers who want to terminate pregnancies and can be change agents.

5. Mothers want safe abortions for their daughters despite concerns about increased sexual activity and can be change agents.

6. Clinic counselors are willing to provide counseling to young women, but their personal values can prohibit them from being effective counselors. Training and values 92

Young Women and Abortion: A situation assessment guide

clarification exercises with staff could potentially make this existing resource more accessible to young women (and young men).

7. Abortion providers are divided in their attitudes toward abortion for young unmarried women. They were willing to listen to different points of view during the session, and there is potential among some for change. They want to better understand the law and seemed interested to know how to interpret it liberally. There is a change agent in the group.

A.12 Using your assessment data Based on our Tuva data analysis we prepared the following intervention plan in collaboration with community partners.

Proposed Intervention

Intervention Objective(s)

Responsible Stakeholders

Students need comprehensive sexuality education, including pregnancy, contraception, STIs and abortion.

Introduce sexuality education in NGO life skills program.

Reduce incidence of unwanted pregnancy and unsafe abortion among young women.

Ipas, NGO program director and coaches.

Get director approval, develop content, and train coaches.

Young people need access to contraceptive counseling and contraceptive methods.

Create new youth services at clinic with after school hours and younger staff.

Increase young women’s use of private, confidential counseling and services at clinic.

Ipas in partnership with clinic director/ staff.

Conduct values clarification with clinic staff.

Key issue/need

Action Steps

Train staff on youth services and confidentiality.

Build youth services room with private entrance and Internet access.

Young women need safe abortion services.

Work with providers to improve attitude, clarify what abortion law permits and support outreach activities to youth in community.

Increase access to and use of safe abortion services for young women whose needs can be defined to match the legal context.

Ipas in partnership with hospital.

Train providers on abortion law.

Conduct values clarification with providers.

Train providers to work with youth.

In Tuva, we decided to focus on both school- and clinic-based education to ensure that services also benefit young people not in school and students who do not participate in the life skills program. We hope that new life skills curriculum content can be developed quickly, while building a room at the clinic and training contraception counselors will take more time.

We feel optimistic from our providers’ session that most are receptive to learning and will become more supportive of services for young women, both married and unmarried.

Appendix A: A situation assessment in ‘Tuva’

93

Appendix B: Sample situation assessment report outline Below is a suggested outline for your situation assessment report with common sections and headings used. This is meant to serve as an example only. It is important to note that the key findings or results section should be organized around learning objectives of the study. An assessment report is likely to have many more subheadings under the results or key findings section than is shown below. The title of the subheadings in the results or key findings section below (4.1-4.6) will also change according to the learning objectives of the assessment. In addition, it is recommended that the questions developed as part of the various assessment methods used (focus group discussion and in-depth interview questions, resource mapping questions, etc.) are included as appendices. Any focus group discussion, in-depth interview, or assessment session reports can also be included as appendices.

Executive Summary 1.

Introduction 1.1

Background

2.

Aims and objectives

3.

Methodology

4.

5.

3.1

Assessment design

3.2

Assessment methods

3.3

Site selection

Results or Key Findings 4.1

Knowledge of pregnancy and contraception

4.2

Sources of SRHR information

4.3

Attitudes towards sex and sexuality

4.4

Sexual behavior

4.5

Access to SRH services, including abortion

4.6

Health service providers’ attitudes

Conclusions and Recommendations Recommended Appendices: Appendix 1: Data Collection Tools Appendix 2: Focus Group Discussion Reports Appendix 3: Resource Mapping Results

94

Young Women and Abortion: A situation assessment guide

For more information or to donate to Ipas: Ipas P.O. Box 5027 Chapel Hill, NC 27514 USA 1-919-967-7052 ipas@ipas.org www.ipas.org CEMYOAS2-E11