Provision of sexual and reproductive health information and Services in Schools
There was unanimity among all respondents about the need for school-based provision of SRH information and services. This approach was viewed as the most appropriate way of addressing challenges that adolescent face in trying to access SRH information and services. Participants noted that there was an increase in enrollment in schools and that many adolescents were in school. Further, they noted that students spend majority of their weekly hours in school. They therefore noted that school-based channels would be the most appropriate platform to disseminate SRH information. The following quotes buttress these points by respondents:
“The most important place is school and at home. Because for especially these Christians you go to churches on Saturdays or Sundays. Isn’t it? Once a week. But school, at least 5 days in a week, so it the best place for educating adolescents on sexual and reproductive health issues” (38-year married male parent, FGD).
“…first of all, the statistics show that most of our young people are in school, so if you want to meet adolescents with information then you might as well go to where they can be found where most of them are. And if most of them are found in schools as the statistics are telling us, then it means that comprehensive sexuality education should start with the schools”(Health Manager 1, IDI).
“I also think that reproductive health services must be provided in schools. Children are exposed to a lot of information than we think. Many of them use the internet to seek information on certain things and the information they get may not be correct, so I think when the schools provide reproductive services, they will be informed on behavioral changes, positive behavioral changes that can help them to grow up as adults in future” (Education Manager-2, IDI).
Parents, education managers and health workers all agreed that there was a need to extend the SRH services in schools and there were little variations in views across the various respondents. Out of the 18 key informants interviewed, 15 supported school-based ASRH services. In FGDs among teachers, 14 of the 18 participants also supported this strategy of providing ASRH service. In FGDs with parents, 16 of 19 female parents and 14 of 20 male parent support this approach. Figure 1 shows a graph depicting the respondents’ views on school-based ASRH services.
Some parents drew on their own experiences to highlight the negative effects of the lack of SRH information and services. One parent, for example, shared her experience with an unplanned pregnancy that led to her dropping out of school:
“For me with my child when I realized his behavior, - he likes being in obscure places with young girls, I cautioned him not to impregnate someone. He should bear in mind that I gave birth at 15 years and for that matter I couldn’t continue with school, so the same thing might happen to any lady so he should be very careful” (42-year female parent, FGD).
Views on range of services to be provided in schools
Participants mentioned health education, counseling services, and provision of sanitary pads as essential services for inclusion in any school-based adolescent health program. As shown in Fig. 2, there were mixed views on distributing condoms to students. Some respondents felt that it was appropriate to distribute condoms to students to enable them have protected sex should they wish to have sex. Those who held this view noted that some adolescents often engaged in unprotected sex and believed that the provision of condoms would prevent unplanned pregnancy and sexually transmitted infections. However, some respondents believed that distributing condoms would promote sexual activity as adolescents “experiment” with the condom. One respondent also noted that the current educational policy did not permit the distribution of condoms in school and suggested that condom distribution should be community-based. The following quotes from respondent illustrate these points:
“….But in our schools we provide the counselling services, we can have the health corner alright where counselling services are provided, where materials are provided for reading, where we could have the sanitary towels or pads and other things. But for now I won’t subscribe to having condoms in school because of our socio-cultural background” (Education Manger 4, IDI).
“To me if they provide these services such as health education, distributing sanitary pad and condoms in school it is a good idea because nowadays if you advise the young ones not to have sex, they will have it. So it should be provided in schools for them to protect themselves” (Male Parent, FGD).
“My brother I told you from the very onset that for now Ghana Education Service doesn’t permit the provision of condoms in our schools. Do you get the point? We have a few though of health corners in our schools… But because our schools we don’t allow the provision of condoms, they don’t give condoms to the children in the school but however just as I said and I reiterate, if you have any condoms to provide let it be community-based” (Education Manger 3, IDI).
Some respondents believed that it would be possible to revise the current prohibition of condom distribution within any school premise. Some education managers believed that if various stakeholders including parents were properly engaged it would be possible to obtain approval.
“Although the current system does not allow the provision of some reproductive health service within school compound, if good consultation among parents, teachers, education managers is done, it will be possible to revise the policy” (Education Manager 1, IDI).
Perceived benefits of providing school-based sexual and reproductive health services
Most participants believed that school-based provision of SRH information and services would help adolescents make good SRH choices and reduce the prevalence of unplanned pregnancies, abortions, and sexually transmitted infections. Participants also noted that access to SRH information and services could reduce school dropout rate among females because those who become pregnant whilst in school are often compelled to drop out of school. The following quotes illustrate these points:
“With the services, it will go a long way in reducing the rate of abortion and teenage pregnancy” (Education Manager-1, IDI).
“My view is they should provide sexual health services in schools, it is a world known issue now that we are having girls getting pregnant in schools but if these services were provided to them, I don’t think they will find themselves in this situations” (Education Manager 2, IDI).
“… it will help them delay becoming pregnancy, get pregnant when they want to, reduce the incidence of STIs and of course all these things will help them to improve their ability to stay in school and also improve their economic status in future” (Adolescent Reproductive Health Expert, IDI).
In FGDs with students, they acknowledged challenges in accessing reproductive health services at the community level. In their view, students who seek such services at the community are often perceived as bad boys/girls and service providers are unfriendly to them. They therefore believe the delivery of these services at the school can increase access and break social barriers inhibiting the uptake of such services at the community as illustrated:
“We cannot go to health facility to do family planning or go and buy condoms because the drugstore seller will say you are a bad girl or boy and may tell your parents. So, those who cannot abstain from sex do it without any protection and some become pregnant in the process. One of our colleagues had to stop school because she became pregnant. So having access to this in the school will help address this” (17 years female student, FGD).
Potential challenges in introducing comprehensive school-based ASRH
Feedback from participants suggested that there might be some challenges in introducing school-based SRH programs. Respondents identified resistance from religious organizations, faith-based schools, teachers and parents as a key challenge. This notwithstanding, some respondents believed that with extensive consultation it would be possible to have wider acceptance. The following quotes illustrate these differing views:
“You see some churches will rise up against it. You know Catholics they are against the use of contraceptives, let alone providing the services at their school” (Education Manager 1, IDI).
“Yes, first is resistance from schools and from teachers but we need to do a lot of advocacy and some orientation for them to look at the benefits of such information before we rush into the school” (Education Manager 3, IDI).
“The only problem we’ll have is our conservative nature as Ghanaians. That’s the only challenge because, for instance, how will the parents feel if the child comes home to tell the mother that they shared condoms for us in school? Or they are doing family planning in schools. Every parent will be alarmed” (Health Manager 3, IDI).
Acceptability of the use of psychologists to provide ASRH services
While there were dissenting views on the use of psychologists to provide school-based SRH information and services (Fig. 3), majority of the participants believed that it was feasible and acceptable to use them for these services to adolescents.
Those who believed that it was appropriate to have trained psychologists noted that using psychologists would enable teachers to focus on their primary responsibility of teaching. To them, even though the current education system allows for the training of teachers to serve as guidance and counseling officers at school, these teachers are not effective because they are still expected to teach. Some participants also observed that some students may not feel comfortable discussing sexual and reproductive issues with their teachers and noted that a neutral person, such as a psychologist, would be more appropriate. Other participants felt that psychologists were better placed to identify students experiencing emotional challenges and to offer timely support and counseling. The following quotes illustrates these views from respondents:
“In our adolescent health program, we have a lot of psychology in it so they may not only provide the services and appropriate information but they are also able to provide the counselling that they need for children because they are many ramifications. A child may have some problem at home and that may manifest in inappropriate sexual behavior and we need such people to be able to delve into the details and be able to provide appropriate counselling for such kids” (Education Manager 3, IDI).
“I think it will be a great advantage for them (psychologists) to come in because they will add to whatever teachers currently provide. Because these kids we have they are very complicated and sometimes when teachers are saying what they know, they will say oh you are supposed to come and teach me science, you are supposed to come and teach me maths, how do you think that you know about sex or you know about the changes that occur to me” (Male Teacher 2, IDI).
“Our parents don’t have time or maybe they don’t feel comfortable teaching us certain things and in the schools too, the teachers may not be able to teach us everything but if we have the psychologists or when we have these experts in the school based on the education and the counselling it can help reduce this teenage pregnancies” (Health Manager 2, IDI).
“Several, quite apart from providing the information, if it so happens that some children have some challenges, you know, there will be the opportunity to intervene with any of the psychotherapy… yes the psychologist can intervene with some form of help, and give some therapy when necessary” (Clinical Psychologist-1, IDI).
On the other hand, some respondents believed that using psychologists was not a feasible approach to addressing SRH challenges among adolescents largely because of the sustainability of such an approach. Specifically, respondents who were opposed to the use of psychologists generally raised concerns about the availability of trained psychologists and how to remunerate them for their services as illustrated:
“And also knowing the number of schools in Ghana and the number of psychologists that will be in the system, I think visiting a school or sometimes they might not be able to visit the school in that case it would not be effective” (Female Teacher, FGD).
“The idea [use of psychologist] is good but the problem will be placement and who to employ them and pay for their services. You know psychologist come with some level of higher education and the money to pay them will be the problem” (Male Teacher, FGD).
“Training psychologists to visit schools is not sustainable…. So just use available structures, we have guidance and counseling coordinators there and what GHS [Ghana Health Service] does is that we train the guidance and counseling coordinators in adolescent sexual and reproductive health so most at times they sometimes even do the referrals to the health facilities” (Health Manager 1, IDI).
“Ehhh, we have to strengthen our counselling department, we have, GES [Ghana Education Service] has counselling department and those department should be strengthened, more psychologist and counsellors would have to be trained, well equipped with an in-depth knowledge in adolescent reproductive health so that we could refer students to that department for a redress” (Headmaster, IDI).
Use of health workers to provide school-based SRH information and services
The results of the study also showed that stakeholders had a positive view on the use of health workers to deliver SRH services in school for adolescents (Fig. 4). According to respondents, using health workers would ensure that adolescents have access to accurate SRH information as well access to services. Using health workers was also perceived as a strategy that could be helpful in linking school-health services to the mainstream health care system for easy referral. These views are illustrated in the following quotes:
“Yes, I agree that health workers should visit schools to talk to the children about sexual and reproductive health. It will help them very well because the health workers can easily refer a student with a problem to hospital to get quick care” (Female Parent, FGD).
“You know that is the work of health workers. They have been trained and they have knowledge on sexual and reproductive health. So it would good to use them” (Male Parent, FGD).
“When we have this adolescent health centers with experts going there to work is very easy, for instance we have Nima, see Nima Cluster of schools for instance if we can establish one there, another cluster of school, Dansoman. You see, when we have these adolescent health centers it will rather help the nation, it will help Ghana, it will help Accra Metro” (Education Manager 1, IDI).
Views on operationalizing the use of psychologists and health providers to deliver school-based SRH services
Study findings underscored the need to address gender-related issues when operationalizing any school-based SRH programs. In FGDs with teachers, parents and students, it emerged that it would be preferable for male service providers to be assigned to male students and vice versa for females. According to respondents, matching the sex of service providers to the target students would increase students comfort in discussing sensitive SRH issues. Religious and cultural reasons for sex-separated programs were also highlighted. These views are illustrated in the following quotes:
“For our Islamic religion, what we are supposed to do is we have the females, we don’t mix the females and the males. So we have to have a psychologist for the female and the psychologist for the male” (46-years Teacher, FGD).
“Madam like, they should separate the boys from the girls so that people can ask questions. When they are mixed, people feel shy to ask some questions which ermm is bothering them. So when they separate the boys from the girls’ people will be able to ask questions and will be given a solution to all their problems” (15-years female student, FGD).
Female students were more concerned about separating male and female students. Female students reported that male students often make fun of them when female reproductive and sexual organs are mentioned. In addition, female students believed that female teachers and service providers have experienced what they may be going through and would therefore be in a better position to explain and provide support to them. The following quotes illustrates these points:
“A female teacher, because she is a woman and she has been what you are going through now. And she will more have knowledge of teaching” (17 years female student, FGD).
“…the boys they like when the teacher is teaching and will be saying, they will be saying vagina and those things about females. The boys will be happy and they will be laughing” (16 years female student, FGD).
The results of the study also showed that to be able to implement such a system will involve some work with the existing bureaucracies and good collaboration with various stakeholders including the Ministry of Education, Ghana Health Service and development partners who are currently engaged in SRH services and education in order not to run into challenges.
“As I said if you do not use the right channels the heads may not allow because they may think you are interrupting their contact hours and those would be the challenges. They will not be ready to give you access to the people so if you use the right channels I don’t think you will have any problem” (Headmistress, IDI).
“This is [a] policy issue and will require bringing all stakeholders together to discuss. If Ghana Education Service make it a policy, than nobody can say no to it. We will implement it” (Teacher, IDI).
The study further found that one approach that could be used to implement school-based adolescent SRH is to organize schools into clusters and have one psychologist or health worker assigned to a specific cluster. This design was suggested to address the challenge of finding an adequate number of trained psychologists. The psychologist could provide age-specific education to a group of students and one-on-one counselling for those with specific psychological problems. These suggestion is illustrated in the following quote:
“What can be done is to group schools, a number of schools or students that can meet at a center, then a trained psychologist can meet with about two hundred, three hundred, five hundred students in a big hall giving the same information at the same time so by that the target groups can be met, I mean the number of children that he can meet will expand and will be more” (Education Manager 2, IDI).
“Psychologist, how many are in the system? We may have to put schools together where you assign on psychologist in-charge” (Education Manager 4, IDI).
“The psychologist can educate a group of students on psychological changes and sexual and reproductive health and can provide counselling to individual students or do group counselling for people with similar problems” (Clinical Psychologist 2, IDI).
Further, stakeholders noted that the use of trained psychologists and health workers for the provision of adolescent and sexual health would require making some changes to the school timetables to cater for the time that would be used to provide such services. Further, some respondents highlighted the need to identify an appropriate service point or room where such services would be provided as privacy is required to assure adolescents that information provided would be treated as confidential. To implement this system of school-based provision of SRH would also require changes in existing policy and acquiring logistics that would be used in the delivery of the service.
“It will not be easy because sometimes the school will tell you they already have the time table for the term. So maybe giving you that enough time they [school] will not agree” (Health Manager 1, IDI).
“….You would have to start from the policy level come to the management and then it transcends to the school level. So the challenge is that you must have the materials that you would use for the education ready, err if you have any teaching and learning materials all these should be ready and it should be down to earth to reach the target group” (Education Manager 6, IDI).
“There should be a space or a room for them. So maybe there wouldn’t be availability of a place for them to work. And then maybe we need to train more of the health personnel because this require extra training to deal with this thing. There should be [an] adolescent nurse, a nurse who… a guru, somebody who knows adolescent health, who has been trained, had extra training on adolescent health to tackle them. So maybe shortage of staff will not allow us to err…reach our goal” (Health Manager 3, IDI).
The paradigm of school-based SRH programs using psychologists and health workers
Figure 5 is a framework developed from the data to explain the contextual issues in using health workers and psychologists to provide SRH services in schools. The study showed that existing sources of SRH information such as parents, teachers, peers, electronic media, community members, churches and mosques had practical challenges. Social norms especially made it difficult for parents and teachers to freely provide these services. The existing guidance and counseling services in school, which serve as channels for providing SRH education and support were being undermined by competing roles as the counselors still had to perform their primary role as teachers. The effect of the lack of access to SRH services is low knowledge among adolescents, high adolescent pregnancy and STIs. Adolescent generally need a positive SRH environment, high knowledge on sexuality, and access to SRH services to able to make informed decision which is not the case in Ghana. To that end, respondents generally believed existing systems were not achieving their objective and felt that it would be appropriate for both trained psychologists and health workers to provide school-based SRH to adolescents. In that opinion, using psychologists and health workers can create this positive environment and increase access to ASHR services. The use of health workers and trained psychologists was viewed to have additional benefits. Specifically, psychologists would be better able to identify and support adolescents with psychosocial problems, while health workers foster referrals to SRH services by creating a link between the school health service and formal health system delivery as diagrammatically presented in the figure. The types of services will include providing health education to various classes, individual counselling for those with psychological and physical problems. Group counselling sessions and family counselling could also be organized for students only and student who have family problems respectively (Fig. 5).
However, stakeholders perceived a number of practical challenges around how this could be implemented. Key among the challenges were how to pay for the services that health workers and trained psychologists would render, and availability of psychologists to cater for all schools. Another important challenge raised was around the acceptability of certain services such as distributing condoms and provision of contraceptives services especially in faith-based schools. Nonetheless, respondents believed that garnering enough support from parents and other stakeholders could help overcome this challenge. In designing school-based SRH programs that would rely on trained psychologists and health workers, our finding underscored the need for gender-sensitive programs that would enable both boys and girls to feel comfortable discussing sensitive issues. Once this is implemented, it is go to affect individual and community level factors that predispose adolescents to negative behavioral tendencies with its associated consequences.