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

BACKGROUND: Adolescent sexual and reproductive health (SRH), problems such as unplanned pregnancies are complex and multifactorial, thus requiring multifaceted prevention interventions. Evaluating the impact of such interventions is important to ensure efficiency, effectiveness and accountability for project funders and community members. In this study, we propose Results Based Management (RBM) as a framework for project management, using the Community Embedded Reproductive Health Care for Adolescents (CERCA) as a case study for RBM. The CERCA Project (2010-2014) tested interventions to reduce adolescent pregnancy in three Latin American countries, Bolivia, Ecuador and Nicaragua. Activities were designed to increase adolescent SRH behaviors in four domains: communication with parents, partners and peers; access to SRH information; access to SRH services; and use of contraception. When the project ended, the outcome evaluation showed limited impact with concerns about accuracy of monitoring and attrition of participants. METHODS: We reviewed and analyzed a series of CERCA documents and related data sources. Key findings from these documents were organized within an RBM framework (planning, monitoring, and impact evaluation) to understand how CERCA methodology and performance might have reaped improved results. RESULTS: Strengths and weaknesses were identified in all three elements of the RBM framework. In Planning, the proposed Theory of Change (ToC) differed from that which was carried out in the intervention package. Each country implemented a different intervention package without articulated assumptions on how the activities of intervention would bring about change. In Monitoring, the project oversight was mainly based on administrative and financial requirements rather than monitoring fidelity and quality of intervention activities. In Impact Evaluation, the original CERCA evaluation assessed intervention effects among adolescents, without identifying success and failure factors related to the outcomes, the nature of the outcomes, or cost-effectiveness of interventions. CONCLUSIONS: This analysis showed that multi-country projects are complex, entail risks in execution and require robust project management. RBM can be a useful tool to ensure a systematic approach at different phases within a multi-country setting.

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

In February 2014, an international congress on Promoting Adolescent Sexual and Reproductive Health (ASRH) took place in Cuenca, Ecuador. Its objective was to share evidence on effective ASRH intervention projects and programs in Latin America, and to link this evidence to ASRH policy and program development. Over 800 people participated in the three-day event and sixty-six presentations were presented.This paper summarizes the key points of the Congress and of the Community Embedded Reproductive Health Care for Adolescents (CERCA) project. It aims at guiding future ASRH research and policy in Latin America. 1. Context matters. Individual behaviors are strongly influenced by the social context in which they occur, through determinants at the individual, relational, family, community and societal levels. Gender norms/attitudes and ease of communication are two key determinants. 2. Innovative action. There is limited and patchy evidence of effective approaches to reach adolescents with the health interventions they need at scale. Yet, there exist several promising and innovative examples of providing comprehensive sexuality education through conventional approaches and using new media, improving access to health services, and reaching adolescents as well as families and community members using community-based interventions were presented at the Congress. 3. Better measurement. Evaluation designs and indicators chosen to measure the effect and impact of interventions are not always sensitive to subtle and incremental changes. This can create a gap between measured effectiveness and the impact perceived by the targeted populations. Thus, one conclusion is that we need more evidence to better determine the factors impeding progress in ASRH in Latin American, to innovate and respond flexibly to changing social dynamics and cultural practices, and to better measure the impact of existing intervention strategies. Yet, this Congress offered a starting point from which to build a multi-agency and multi-country effort to generate specific evidence on ASRH with the aim of guiding policy and program decision-making. In a region that contains substantial barriers of access to ASRH education and services, and some of the highest adolescent pregnancy rates in the world, the participants agreed that there is no time to lose.

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

BACKGROUND AND OBJECTIVES: The prevalence of teenage pregnancies in Nicaragua is the highest in Latin-America. This study aimed to gain insight into factors which determine the sexual behaviours concerned. METHODS: From July until August 2011, a door-to-door survey was conducted among adolescents living in randomly selected poor neighbourhoods of Managua. Logistic regression was used to analyse factors related to sexual onset and contraceptive use. RESULTS: Data from 2803 adolescents were analysed. Of the 475 and 299 sexually active boys and girls, 43% and 54%, respectively, reported contraceptive use. Sexual onset was positively related to increasing age, male sex, alcohol consumption and not living with the parents. Catholic boys and boys never feeling peer pressure to have sexual intercourse were more likely to report consistent condom use. Having a partner and feeling comfortable talking about sexuality with the partner were associated with hormonal contraception. CONCLUSIONS: Our data identified associates of adolescents' sexual behaviour related to personal characteristics (sex and alcohol use), to the interaction with significant others (parents, partners, peers) and to the environment (housing condition, religion). We interpreted those associates within the context of the rapidly changing society and the recently implemented health system reform in Nicaragua.

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

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

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

The Community-Embedded Reproductive Health Care for Adolescents (CERCA) Project was implemented in Bolivia, Ecuador and Nicaragua (2011-2014) to test the effectiveness of interventions preventing teenage pregnancies. As the outcome evaluation showed limited impact, a post-hoc process evaluation was carried out to determine if and how CERCA's design, implementation, monitoring and evaluation affected the results. We did a document analysis and conducted 18 in-depth interviews and 21 focus group discussions with stakeholders and beneficiaries. Transcripts were analyzed using directed content analysis. Data showed that CERCA sensitized stakeholders and encouraged the discussion on this sensitive issue. In terms of design, a strong point was the participatory approach; a weak point was that the detailed situation analysis was completed too late. In terms of implementation, a strong point was that multifaceted activities were implemented; a weak point was that the activities were not pilot tested for feasibility/acceptability and evolved substantially throughout the Project. In terms of monitoring, strong points were that regular monitoring kept the Project on track administratively/financially; a weak point was that monitoring indicators did not change as the intervention package changed. In terms of evaluation, weak points were the substantial attrition rate and narrow focus on adolescents. This study provides recommendations for future projects.

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

BACKGROUND: To meet the needs of female adolescents from low-income urban areas for sexual and reproductive health (SRH) care, vouchers providing free-of-charge access to SRH care at 19 primary care clinics were distributed in Managua, Nicaragua. These vouchers substantially increased the use of services, demonstrating that many adolescents are willing to use such services, if readily accessible. The voucher redemption made it possible to identify the nature of existing, but largely unmet, needs for SRH care. METHOD: The medical files from 3301 consultations with female adolescents were analysed using descriptive statistical methods and multiple logistic regression. RESULTS: Female adolescents presented SRH problems that merited medical attention. The mean number of problems presented was 1.5 per consultation: 34% of the vouchers were used for contraceptives, 31% for complaints related to sexually transmitted infection (STI) or reproductive tract infection (RTI), 28% for advice/counselling, 28% for antenatal check-up and 18% for pregnancy testing. A new category of health care users emerged: sexually active girls who were neither pregnant nor mothers and who sought contraceptives or STI/RTI treatment. Contraceptive use doubled among the sexually active non-pregnant voucher redeemers. Consultation with a female doctor younger than 36 years was associated with a higher chance of having contraceptives prescribed. CONCLUSION: Accessible and appropriate SRH care has the potential to make an important contribution to the increased contraceptive use, decreased risk of unwanted teenage pregnancies and decreased prevalence of STIs/RTIs among underserved adolescents. Once adolescents access the services, providers have a crucial role in ensuring current and continuing needs are met.

The cost-effectiveness of a competitive voucher scheme to reduce sexually transmitted infections in high-risk groups in Nicaragua.

Current evidence suggests that sexually transmitted infection (STI) interventions can be an effective means of human immunodeficiency virus (HIV) prevention in populations at an early stage of the epidemic. However, evidence as to their cost-effectiveness when targeted at high-risk groups is lacking. This paper assesses the cost-effectiveness of a competitive voucher scheme in Managua, Nicaragua aimed at high-risk groups, who could redeem the vouchers in exchange for free STI testing and treatment, health education and condoms, compared with the status quo (no scheme). A provider perspective was adopted, defined as: the voucher agency and health care providers from the public, NGO and private sectors. The cost of the voucher scheme was estimated for a 1-year period (1999) from project accounts using the ingredients approach. Outcomes were monitored as part of ongoing project evaluation. Costs and outcomes in the absence of the scheme were modelled using project baseline data and reports, and relevant literature. The annual cost of providing comprehensive STI services through vouchers was US$62 495, compared with an estimated US$17 112 for regular service provision in the absence of the scheme. 4815 vouchers were distributed by the voucher scheme, 1543 patients were tested for STIs and 528 STIs were effectively cured in this period. In the absence of the scheme, only an estimated 85 cases would have been cured from 1396 consultations. The average cost of the voucher scheme per patient treated was US$41 and US$118 per STI effectively cured, compared with US$12 per patient treated and US$200 per STI cured in its absence. The incremental cost of curing an STI through the voucher scheme, compared with the status quo, was US$103. A voucher scheme offers an effective and efficient means of targeting and effectively curing STIs in high-risk groups, as well as encouraging quality care practices.