UNIT 9: CONTRACEPTION AND RISK REDUCTION COUNSELING FOR ADOLESCENTS INTRODUCTION: Adolescents often do not have access to sexual and reproductive health information and services. This lack of access often results in misinformation and a limited ability to make responsible and appropriate decisions about protecting themselves from disease and pregnancy. Providers and counselors have an important role to play in both educating young people and facilitating responsible decision-making. Protection against infection and pregnancy involve many of the same strategies and services. Adolescents need to be able to first assess their risk of STI/HIV or of an unintended pregnancy, and then identify steps they can take to protect their sexual health and mitigate risk. Providers need to be able to comfortably discuss sexual health and sexual activity with adolescents, and to provide accurate information on risks that may be associated with sexual activity as well as actions young people can take to reduce their risk. One important action that providers can take is to dispel myths and correct misinformation about contraception such as commonly held concerns around the side effects of contraceptive methods. This can help to ensure that the adolescent client will choose to use a method of contraception and continue to use it properly. TrainerÕs Note: This unit is designed to be delivered with youth trainers. The lesson and activities can be modified for an adult provider-only participant group, but trainers are strongly encouraged to include youth participants. The participation of youth trainers with different types of disabilities is essential to ensure the perspectives of clients with disabilities are included in the training. Accommodation (sign language interpretation and/or Computer Aided Real-Time Transcription (CART) 1 personal assistants, braille, large print, easy to read materials, etc.) should be provided according to the needs to ensure full participation of young trainers with disabilities UNIT TRAINING OBJECTIVE: To prepare providers to effectively counsel adolescents on safer sex including contraception. SPECIFIC LEARNING OBJECTIVES: By the end of the unit, participants will be able to: 1. Identify reasons why adolescents may not use protection and effectively dispel misinformation and rumors. 2. Discuss safer sex messages and actions to prevent STIs, HIV, and unintended pregnancy, including contraceptive options available to adolescents. 3. Demonstrate how to counsel adolescents, including young men, about contraception and dual protection strategies to prevent STIs, HIV, and unintended pregnancy. TOTAL TIME: 3 HOURS 45 MINUTES UNIT OVERVIEW: Session Methods Materials Time 9.1 Brainstorm Trainer presentation Slides 9.1-9.5 Index cards Flipcharts and markers 40 minutes 9.2 Trainer presentation Group discussion Slides 9.6-9.21 Participant Handouts 9a Contraceptive cue cards 1 hour 15 minutes 9.3 Role plays Participant Handouts 9a and 9b Contraceptive cue cards IEC materials (if available) 1 hour 30 minutes Unit Summary Feedback discussion 20 minutes WORK FOR TRAINERS TO PREPARE IN ADVANCE: * Review Slides 9.1-9.21 * Work with youth co-trainers to plan delivery * SO 9.1 Index cards (5 per participant) * SO 9.2 Prepare copies of PathfinderÕs Cue Cards for Counseling Adolescents on Contraception for each participant. The cue cards can be downloaded here: http://www.pathfinder.org/publications/cue-cards-for-counseling-adolescents-on-contraception/. They can also be found in hard copy in Handout 9b. * SO 9.2 Prepare Participant Handout 9a: BCS+ Algorithm * SO 9.3 Prepare Participant Handout 9b: ASRH Counseling Role Plays * SO 9.3 Collect or ask participants to bring in existing IEC materials on contraceptives from their clinics. MAJOR REFERENCES AND TRAINING MATERIALS: Jones, N., Presler-Marshall, E. and Stavropoulou, M. 2018. Adolescents with disabilities. Enhancing resilience and delivering inclusive development. London: Gender and Adolescence: Global Evidence Population Council, 2015. Balanced Counseling Strategy Plus: A Toolkit for Family Planning Service Providers Working in High STI/HIV Prevalence Settings; TrainerÕs Guide, Third Edition. Washington, DC: Population Council. UNAIDS. 2017. Disability and HIV. UNAIDS. Available at https://www.unaids.org/sites/default/files/media_asset/JC2905_disability-and-HIV_en.pdf WHO medical eligibility criteria wheel for contraceptive use Ð 2015 update. http://apps.who.int/iris/bitstream/handle/10665/173585/9789241549257_eng.pdf?sequence=1 SPECIFIC OBJECTIVE 9.1: IDENTIFY REASONS WHY ADOLESCENTS MAY NOT USE PROTECTION AND DISPEL MISINFORMATION AND RUMORS TIME 40 minutes METHODS * Group brainstorm activity * Trainer presentation MATERIALS NEEDED * Index cards (5 per participant) * Flipcharts and markers * Slides 9.1-9.5 STEPS Time: 20 minutes 1. Introduce the activity by explaining to participants that there are many reasons why adolescents are particularly at risk for STIs/HIV and unintended pregnancy. There are also many reasons why it is particularly important to help adolescents avoid STIs, including HIV, and unintended pregnancy. Say that some adolescents will seek services because they want to prevent pregnancy, while others may want to prevent HIV. Explain that every service session with an adolescent is a chance to integrate information on STIs, HIV, and pregnancy prevention and to promote dual protection: protection against infection and pregnancy. > TrainerÕs Note: If there is a youth co-trainer, have them lead/facilitate this activity. 2. Pass out 5 index cards to each participant. Tell them that first weÕre going to try to put ourselves in the mindset of an adolescent, because we can better plan for counseling adolescents if we understand the context in which they make decisions about sexual behavior. 3. Have participants write one reason why adolescents have unprotected sex on each of their index cards. Give them 5 minutes to complete their cards. 4. Collect the cards and group them according to similar responses. The youth facilitator should at this point supplement participantsÕ responses with their own responses, and any missing content you judge important from Supplemental Content: Reasons Why Adolescents May Have Unprotected Sex. Supplemental Content: Reasons Why Adolescents May Have Unprotected Sex * May think they are not vulnerable to pregnancy or STIs/HIV. ÒIt canÕt happen to meÓ or "I don't have sex often enough to get pregnant or contract a STI/HIV." * May not have adequate or accurate information about sexuality or protection. * Sexuality education is often non-existent or inadequate in both schools and the community. * Parents and others are reluctant to provide practical information and may believe that providing information encourages sexual activity. (Research shows this is not true: sexuality education actually facilitates safer behaviors.) * Media promotes unrealistic notions of sexuality (Òsex sellsÓ) and usually omits any mention of risk or protection. * DonÕt know what methods are available. * DonÕt know where, how, or when to get methods. * May not be aware of the need for protection during every sex act (i.e. may think that oral or anal sex are ÒsafeÓ alternatives to vaginal sex). * Believe their peers are not using contraception or protection. * In addition to the above mentioned factors, which can be common to all adolescents, adolescents with disabilities face additional barriers in accessing information about methods and need for protection, which increase their risk of engaging in unsafe behavior. These include not only communication barriers but also attitudinal barriers at the service providers, school, community or family level based on the widespread lack of understanding of sexuality and disability and the misconception that adolescents with disabilities are not sexually active and, therefore, do not need to access SRH information. Misinformation or Misconceptions * May have misinformation or myths about methods and their side effects. Myths about the dangers of contraception are common and difficult to correct. * May not believe that protection is needed with a regular partner. * May not believe that protection is needed if their partner looks healthy. * May think that STI/HIV transmission only occurs among "certain people" (for example, commercial sex workers, poor people, "other" ethnic groups) and not among others (for example persons with disabilities). * May be under social pressure to ÒproveÓ their fertility. * May believe that social norms associate use of contraceptives with Òplanning for sexÓ and promiscuity. * May be using ineffective or potential harmful traditional remedies for pregnancy or STIs. * Believe that sexual desire is uncontrollable or could result in injury or illness if not fulfilled. Denial * "Sex just happened." * "I only had sex once." * Believe "sex should be spontaneous" or are under social pressure to behave as though sex is/was spontaneous. * They don't think they will get pregnant or contract a STI. Lack of Access * Access to contraceptive services (including protection) for adolescents is limited by law, custom, or clinic/institutional policy. * Availability and high cost of certain methods. * Irregular supply of methods. * Social pressure that associates contraceptives with promiscuity. * Adolescents believe/behave as though sex is spontaneous so are less likely to have a method available when sex happens. * Judgmental attitudes or personal beliefs of the provider may prevent them from distributing certain methods to adolescents. * Some vulnerable or marginalized groups of adolescents often face additional barriers to accessing contraceptive information and services. In the case of adolescents with disabilities, these include but are not limited to physical, communication and attitudinal barriers. See the chapter ÒAdolescents with DisabilitesÓ for additional information on disability-based barriers. Coercion * Partner or family wants pregnancy. * Partner won't let her/him use protection or insists that use of contraceptives is a sign of mistrust. * Sex is forced or coerced. * Belief that condoms ruin sex or are unromantic. * Partner agrees to use contraceptives or protection but then refuses to follow through. Fear * Rejection by partner. * Lack of confidentiality at the place where they obtain methods. * Fear of the unknown - of using something that they have never used before. * Side effects. * Limited understanding of how to properly use protective methods. * Where to keep protective methods so that no one sees/discovers them. * Something may go wrong if they start using certain methods or products in adolescence. * Their parents will find out they are having/planning to have sex. * Their peers will know they are sexually active. * Concerns over a physical examination, especially pelvic exam. * Being asked questions by medical staff. * Being labeled as "cheap" or "loose" or Òbad.Ó * Being seen entering a clinic. Embarrassment * Service providers are sometimes judgmental and/or moralistic about adolescent sexual activity. This is particularly true in the case of adolescents with disabilities because of the widespread misconceptions and lack of knowledge on sexuality and disability. * Embarrassed to buy condoms. * Retail outlets often place protective methods behind the counters so that customers must request them. * May be embarrassed to use a method at the time of sex. Other factors * Stopped using contraceptives because of the side effects. * Sex may be spontaneous or unplanned. * In some instances, adolescents want to conceive. Girls/young women may see pregnancy as a way to keep a relationship or a boyfriend; for a boy/young man, pregnancy may be seen as a way to prove manhood. * May lack the communication and negotiation skills to discuss contraception/protection. * Thinks the partner "is taking care of contraception." * Feels ambivalent about becoming pregnant. * Does not know how to dispose of condoms. 5. Have the group discuss the following questions in plenary (Ensure that youth facilitators/participants with and without disabilities are leading the discussion and are encouraged to respond to any assumptions or misconceptions expressed by participants): a. Which of these reasons are internal to the adolescent (that is, based on their own self-awareness or self-perception)? b. Which are external (that is, based on social norms or cultural barriers)? c. What are some counseling strategies you could use to help an adolescent express his or her concerns or misconceptions? (TrainerÕs note: select individual cards and ask for specific strategies or techniques. Use a flip chart during this question and the next to create a record for participants.) d. What other support could you provide? 6. Close the discussion by asking youth participants/facilitators for their reactions and advice for providers. Ask participants/facilitators with disabilities in the room for their specific insights and experiences on disability-based barriers and advice for providers. Time: 20 minutes 7. Move to the trainerÕs presentation. This presentation should be delivered by both the lead trainer and a youth counterpart, if available. The trainers should work together beforehand to decide how best to divide the information, with a preference towards the youth trainer delivering more of the content. 8. Start the presentation by explaining that rumors and misconceptions about contraception, about how they will be treated at clinics, and how the community perceives their actions, are some of the reasons why adolescents and even adult clients fail to access available services. Service providers working with adolescents need to be prepared to address the myths, misconceptions, and rumors that clients may express to best counsel them on dual protection. 9. Present Content: Rumors (Slides 9.1-9.5) below. Content: Rumors (Slides 9.1-9.5) Slide 9.1: Rumors Rumors are unconfirmed stories that are transferred from one person to another by word of mouth. Increasingly, rumors are spread on social media. Rumors are common among adolescents. In general, rumors arise when: * An issue or information is important to people, but it has not been clearly explained. * There is nobody available who can clarify or correct incorrect information. * The original source is seen to be credible. * Social taboos prevent adolescents from seeking correct information from trusted adults. * People are motivated to spread them for political or social reasons. 10. Pause and ask participants to think of some common rumors in their community. 11. Return to the presentation with Slide 9.2: Misconceptions below. Slides 9.2-9.3: Misconceptions A misconception is a mistaken interpretation of ideas or information. If a misconception is filled with details and becomes a fanciful story, then it acquires the characteristics of a rumor. Rumors can play a big role among adolescentsÕ perceptions and beliefs because they are often cut off from or denied information about sexual and reproductive health and are eager to fill "in the blanks." Rumors and misinformation can also come from other sources in the community: the media is often a source of misinformation or incomplete information for all members of the community. Parents, faith leaders, teachers, and community leaders may not possess correct information on or understanding of adolescents and sexual and reproductive health and may perpetuate potentially dangerous stereotypes and misconceptions about adolescent sexuality and sexual risk. Rumors or misconceptions may even be spread by health workers who may be misinformed about adolescents and their abilities to use certain methods. They may hold beliefs pertaining to contraception and adolescent sexuality that are influenced by their culture or religion which they allow to affect their professional conduct. The underlying causes of rumors have to do with people's knowledge and understanding of their bodies, health, medicine, and the world around them. Often, rumors and misconceptions about contraception make sense to clients and potential clients, especially to young people. Slides 9.4-9.5: Methods for Counteracting Rumors and Misconceptions When a client mentions a rumor, always listen politely. Don't laugh. Take the rumors seriously. Define what a rumor or misconception is. Normalize the rumor or misconception through statements like ÒA lot of people have that beliefÓ or ÒI can see why youÕd think so, butÉÓ Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor. Explain the facts using accurate information but keep the explanation simple enough for young people to understand. Use strong scientific facts about contraceptives and sexual risk to counteract misinformation. Always tell the truth. Never try to hide side effects or problems that might occur with various methods. Never overstate or exaggerate the level of risk associated with sexual behaviors. Give examples of people who are satisfied users of the method (only if they are willing to have their names used). This kind of personal testimonial is most convincing. Reassure the client by offering STI/HIV and/or pregnancy testing or routine sexual and reproductive health exams and discuss the findings. Counsel the client about all available contraceptive methods. Use visual aids and actual contraceptives to explain the facts. Remember to provide the accommodations needed by the persons with disabilities in the room to ensure full participation. 12. Conclude your presentation by asking participants to look back at the flip charts from the previous discussion with strategies for counteracting rumors. Ask them to think about which theyÕve used, and if there are any new strategies theyÕd like to try when they go back to their clinics. SPECIFIC OBJECTIVE 9.2: DISCUSS SAFER SEX MESSAGES AND TECHNIQUES IN THE PREVENTION OF STIS AND UNINTENDED PREGNANCY, INCLUDING CONTRACEPTIVE OPTIONS AVAILABLE TO ADOLESCENTS TIME 1 hour 15 minutes METHODS * Trainer presentation MATERIALS NEEDED * Slides 9.6-9.21 * Participant Handout 9a: BCS+ Algorithm * Participant Handout 9b: Contraceptive Cue Cards STEPS > TrainerÕs Note: This presentation should be delivered by both the lead trainer and a youth counterpart, if available. The trainers should work together beforehand to decide how best to divide the information, with a preference towards the youth trainer delivering more of the content. The participation of youth trainers with different types of disabilities is essential to ensure the perspectives of clients with disabilities are included in the training. Accommodation should be provided according to the needs to ensure full participation of young trainers with disabilities. Time: 45 minutes 1. Start by reminding participants that addressing adolescent clientsÕ misconceptions is only the beginning of the service relationship. Explain that this session will contain a lot of information, and in the next session the group will practice putting both their strategies for addressing misconceptions and the information and methods contained in this session into practice. 2. Begin the presentation Content: Adolescent SRH Landscape (Slides 9.6-9.21) below. Slide 9.6-9.8: Global Statistics Adolescents seek services for multiple reasons: maybe they are concerned about HIV infection, or preventing unintended pregnancy. Maybe theyÕre experiencing symptoms that could be an STI or a similar infection. Some adolescents will come for ante-natal visits or because they are already pregnant or have given birth. Some will come for post-abortion care or because they have an infection from an unsafe abortion. According to WHO: * About one half of all people infected with HIV are under the age of 25. * About half of all new HIV infections occur among young people aged 15-24. * An estimated 1 in 20 youths contract STIs each year and one-third of all STIs occur among 13-20-year-olds (110 million STIs/year). * In many African countries, up to 20% of all births are to women 15-19 years old. * Anywhere from 40-70% of women have become pregnant or mothers by the end of their teens in many African countries. * In many Latin American countries, 35% of women hospitalized for septic abortion are under age 20. * In some countries, maternal deaths are 2-3 times greater in women 15-19 years old than in women 20-24 years old. * Condom use among young people is greater than among older people. * Similar SRH global data disaggregated by age and disability are not yet available. On HIV, the data available from sub-Saharan Africa suggests an increased risk of HIV infection of 1.48 times in men with disabilities and 2.21 times in women with disabilities compared with men without disabilities. It is possible to assume that adolescents with disabilities are exposed to the same or even a higher increased risk. These statistics show that young people are vulnerable when it comes to their sexual and reproductive health. Every interaction with an adolescent client is an opportunity for service integration, in particular when it comes to protection against infection and unintended pregnancy. Because young women already seek care because of pregnancy and abortion care, we may have the opportunity to educate, prevent and treat STIs in this setting. Young men may be more likely to come for STI/HIV testing and should be counseled on contraception and sexual health. 3. Pause and ask participants to reflect on the following terms. Go around the group in a circle and ask them to share the first thing that pops into their head when you say each of the terms. Encourage participants to freely say the first thing that pops into their heads and not worry about ÒrightÓ or ÒwrongÓ answers: * Unprotected sex * Risk behavior * Safe sex * Protected sex 4. Ask the group if they noticed any trends in the answers. Were there positive responses associated with safe sex? Protected sex? What about unprotected sex? Were there negative responses associated with safe or protective sex? If so, ask why participants think the responses were so varied. If responses werenÕt varied, ask why not. Is there a dominant cultural norm associated with these terms? 5. Return to the presentation. Slides 9.9-9.11 Sexually transmitted infections are infections that are spread through sexual contact, including vaginal, anal, and oral intercourse. Some can be spread through touching and kissing. Sexual protection is anything that can be done to lower the risk of sexually transmitted infections, including HIV, and pregnancy. Sexual protection reduces risks and can be practiced without reducing pleasure. Many programs and governments promote abstinence until marriage as the only sexual protection option appropriate for adolescents, referring to abstinence as 100% effective. This is a false statement. Total abstinence from sexual activity will of course protect anyone from STIs and unintended pregnancy, but just like any other method of protection, abstinence has a failure rate. The failure rate for abstinence is higher for typical use than other contraceptive methods. For example, some programs narrowly define abstinence as abstaining from penetrative vaginal sex, which leaves adolescents with the mistaken impression that oral or anal sex, because they cannot result in a pregnancy, are Òsafe.Ó For an unacceptably high number of adolescent girls, sexual activity is forced or coerced, and public promotion of abstinence as the only method that is morally appropriate for young people can create feelings of shame and stigma. Abstinence is also an impractical standard to hold adolescents to; it can be encouraged for those who feel they are not yet ready for sexual activity but should not be held up as the only option for protection against STIs, HIV, and unintended pregnancy. The promotion of abstinence until marriage also discriminates against and excludes adolescents from sexual minority groups who may not legally be allowed to marry the partner of their choosing. Other programs promote "Safer Sex," which describes a range of ways that sexually active people can protect themselves from most STIs, including HIV. Practicing safer sex also provides protection from pregnancy. Counseling adolescents on safer sex and sexual protection focuses on first helping young people to assess the relative risk of various sexual practices. Slide 9.12: No Risk There are many ways to explore your sexuality that are not risky. Some of them include hugging, holding hands, massaging, rubbing against each other with clothes on, sharing fantasies, masturbating your partner or masturbating together, as long as men do not ejaculate near any opening or broken skin on their partners. Slide 9.13: Low Risk There are other activities that are mostly safe such as using a latex or polyurethane condom or other barrier for every penetrative act of sexual intercourse (penis, fingers, or other objects in vagina, anus, or mouth), and using a barrier (such as a latex dental dam, a cut-open condom or plastic wrap) for oral sex on a woman or for any mouth to anus contact. Most kissing is also safe, provided neither partner has any cuts or sores on, in, or around their mouths. Slide 9.14: Medium Risk There are activities that carry some additional risk, such as introducing an injured finger or hand into the vagina or anus or sharing sexual toys (rubber penis, vibrators, etc.) without cleaning them. Slide 9.15: High Risk There are activities that are very risky, because they lead to exposure to the body fluids in which most STIs, including HIV, live. These include having any kind of sexual intercourse without using a condom or having oral sex without a latex barrier. Sex which is coerced or non-consensual and forceful may also carry additional risk due to likelihood of small cuts or tears resulting from violence. Slide 9.16: Dual Protection Dual protection is the consistent use of a male or female condom alone or in combination with a second contraceptive method (e.g. hormonal or permanent). Adolescents who seek contraception may only be provided with a method that protects them from pregnancy. As providers, we should ensure that all adolescents are using a method or combination of methods that protect them from both pregnancy and STIs/HIV. Time: 30 minutes 6. Pause for questions. While taking questions, distribute Participant Handout 9a: BCS+ Algorithm. 7. Introduce the handout. Explain that this session will cover the basics of the Balanced Counseling Strategy +, which is a counseling method developed by the Population Council and their partners, and one that Pathfinder recommends for service providers. There are more tools available on Population CouncilÕs website: http://www.popcouncil.org/research/the-balanced-counseling-strategy-plus-a-toolkit-for-family-planning-service 8. Present Slide 9.17: The BCS+ Approach Slide 9.17: The BCS+ Approach The BCS+ approach is divided into 4 stages: * Pre-Choice Stage The service provider establishes a relationship with the client and learns about their current and desired family size, timing, and contraceptive choices. * Method Choice Stage The provider counsels the client on available methods and empowers them to choose their preferred contraceptive option. * Post-Choice Stage The provider reviews the clientÕs method of choice in detail, discusses side effects, and helps the client set a follow-up plan for continued contraceptive use. * Systematic Screening for Other Services Stage The provider reviews the clientÕs risk for STIs, including HIV, discusses dual protection strategies, and addresses other reproductive health concerns. It is important to remember that adolescents particularly benefit from dual protection information and strategies. Allow adequate opportunity for them to ask questions and provide quality, non-judgmental information. 9. Pause for questions and to give participants time to review the handout. While discussing any questions, distribute Adolescent Contraceptive Cue Cards to participants. 10. State: Pathfinder believes that sexually active adolescents should have access to the full range of contraceptive methods, including LARCs. The World Health Organization Medical Eligibility for Contraceptive Use supports this belief, stating that age and parity are not contraindications for any method. In fact, users of short-acting methods, particularly adolescents aged 15 to 19, are more prone to contraceptive failure than users of LARCs. 11. Say: These Contraceptive Cue Cards describe the various forms of contraception that are commonly available and should be discussed with adolescents. However, we know that not all of these methods may be available in your clinics or community, and in some cases there may be legal or policy restrictions on which methods adolescents may obtain. 12. Present Slide 9.18: Contraceptive Methods. Slide 9.18: Contraceptive Methods Contraceptive methods are generally classified into one of three categories: * Short-acting * Long-acting reversible contraceptives (LARCS) * Permanent methods Both short-acting and LARCs are appropriate for adolescent use. There is a growing international medical and advocacy consensus that adolescents should be able to obtain and use LARCs, given their effectiveness at preventing unwanted or unintended pregnancy. 13. Say: the BCS+ method requires you to be aware of which methods are available and which methods are best for adolescents based on their current and future pregnancy desires. Counseling and discussion will reveal which contraceptive methods are likely to be best suited for individual adolescent clients, but you should be aware of the following general recommendations: * All adolescents need to be counseled on the importance of using dual protection against STIs, HIV, and unintended pregnancy. Condoms can prevent pregnancy, STIs and HIV, or adolescents can choose to use a contraceptive method for effective prevention of pregnancy and a barrier method (condoms). * LARCS are a medically acceptable and recommended strategy for adolescents, which can be used to both delay and space pregnancy. * All adolescents regardless of gender should be counseled on their risks and responsibilities for their sexual and reproductive health, including prevention strategies for STIs and unintended pregnancy. 14. Return to the presentation with Slide 9.19: Side Effects and Their Effect on Clients. Slidess 9.19-9.21: Side Effects and Their Effect on Clients Research has shown that the leading reason women, and especially young women, donÕt use or discontinue use of a contraceptive method is due to misinformation about or mismanagement of side effects. Providers must fully inform their clients about potential side effects of their chosen method, how best to manage side effects and when to follow up with the provider for support in managing side effects or to switch methods. It is important to emphasize that most side effects from modern family planning methods pose no health risk to clients. However, providers should take them seriously because they can be uncomfortable, annoying, or worrisome to adolescent clients. For example: A young woman who is using DMPA may experience spotting or amenorrhea. This side effect may lead her to believe that she is pregnant or, conversely that that she will not be able to become pregnant. Some young women tolerate side effects better than others. Every womanÕs experience (pain, discomfort, weight gain, etc) is very individual. For example: Some adolescents may not be bothered by weight gain but other young women may become very upset by a weight gain of even a few pounds (which may or may not be due to using a family planning method). Changes in menstrual patterns may bother some young women, while others may see it as a benefit. Side effects are the major reason that clients stop using a method. Providers must: * Not be dismissive of the adolescent clients concerns. * Be patient and empathetic with all client complaints. * Offer clients an opportunity to discuss their concerns. * Reassure that side effects usually resolve in a few months. * Differentiate side effects from complications. * Offer clients good technical and practical information, and advice about how to deal with side effects. * Provide information/handouts for the client on side effects in local languages. * Recommend follow-up. 15. Ask participants to list some of the side effects that clients have expressed concern about. In small groups, have participants discuss and compare the side effects for the methods of contraception available in their clinics, using the Contraceptive Cue Cards. Ask if there are any side effects they are unfamiliar with, or methods they would like to review in further detail. Take time to discuss any concerns or questions. 16. Conclude the presentation by informing participants that the next session will be focused on practicing using the information learned so far. PARTICIPANT HANDOUT 9A: BCS+ ALGORITHM (SOURCE POPULATION COUNCIL) Algorithm for Using the Balanced Counseling Strategy Plus THIRD EDITION, 2015 1 BRIEFLY REVIEW THE METHODS THAT HAVE NOT BEEN SET ASIDE AND INDICATE THEIR EFFECTIVENESS. a) Arrange the remaining cards in order of effectiveness (see back of each card). b) In order of effectiveness (highly effective to not effective), briefly review the attributes on each method card. 2 ASK THE CLIENT TO CHOOSE THE METHOD THAT IS MOST CONVENIENT FOR HER/HIM. a) If client is adolescent use the counseling card to inform her that she can get any method 3 USING THE METHOD-SPECIFIC BROCHURE, CHECK WHETHER THE CLIENT HAS ANY CONDITION FOR WHICH THE METHOD IS NOT ADVISED. a) Review ÒMethod not advised if you...Ó section in the brochure b) If the method is not advisable, ask the client to select another method from the cards that remain. Repeat the process from Step 8. HANDOUT 9B: CONTRACEPTIVE CUE CARDS **Note: The Cue Cards for Counseling Adolescents on Contraception are up to date as of 2016. 2020 update: The contraceptive cue cards are currently being updated to include DMPA-SC and to ensure they appropriate reflect most up-to-date global guidance. Once cue cards are updated, these will be replaced with the new version SPECIFIC OBJECTIVE 9.3: DEMONSTRATE HOW TO COUNSEL ADOLESCENTS, INCLUDING YOUNG MEN, ABOUT CONTRACEPTION AND DUAL PROTECTION TO PREVENT STIS AND UNINTENDED PREGNANCY TIME 1 hour 30 minutes METHODS * Role plays MATERIALS NEEDED * Participant Handout 9a: BCS+ Algorithm * Participant Handout 9b: Contraceptive Cue Cards * Participant Handout 9c: AYSRH Role Plays STEPS: > TrainerÕs Note: Work with the youth trainer or another trainer. The two trainers should use role play to demonstrate examples of what constitutes ÒpoorÓ counseling and an ÔimprovedÓ counseling process. It is essential to ensure the participation of youth trainers with different types of disabilities within the training. Accommodation should be provided as needed. Time: 10 minutes 1. Set up two chairs at the front of the room. Demonstrate a role play with your youth co-trainer of a ÒpoorÓ counseling and an ÒimprovedÓ counseling experience for an adolescent client. The demonstration of a poor procedure should come first, followed by analysis and feedback. 2. When performing the improved counseling role play, apply the BCS+ method, so that participants can observe an example of how that approach should work. 3. Ask participants to analyze the demonstration and provide feedback on what was positive or negative, what was missing, and whether there was wrong or incomplete information presented. 4. After the trainer demonstration, divide the participants into small groups of 3-5 for simultaneous role plays. Keep the number of groups to a size where the trainer(s) can observe role plays easily by moving around the room. For example, if there is one trainer, divide participants into fewer, larger groups. If there are multiple trainers and youth trainers, divide the participants into groups of three. Time: 1 hour 20 minutes 5. Ask the participants to perform role plays, using information from Participant Handout 9c: AYSRH Counseling Role Plays, Participant Handout 9a: the BCS+ Algorithm, and Participants Handout 9b: Contraceptive Cue Cards, and local IEC materials if available. Each participant should participate in three role plays and play each of the following roles at least once (more if the trainer feels a participant needs more practice): * Client * Provider * Observer > TrainerÕs Note: If an exam or medical procedure would normally be done when providing a contraceptive method, participants should announce to the observers what they would do if they were in the clinic (i.e. now I would take the Blood Pressure). 6. Each participant is expected to participate actively in the role play process, as both a player and observer, and in group discussions and feedback. 7. Trainers should rotate groups after the first one or two role plays to get as many trainer observations of individual participantsÕ counseling skills as possible. 8. Observe and assess each participant for both counseling content, process, and participation in the exercise. 9. Allow actors/players about 10 minutes to prepare, limit each role play to 5 minutes, and allow about 15 minutes for feedback and analysis of the process and content. 10. Encourage and guide the participants in using constructive critique, analyzing what was good about the way the counselor handled the counseling and suggesting what could be improved. 11. Remind participants not to confuse the actual participant with the actor's role, and that feedback and critique must not be personalized. 12. The trainer's role during feedback/ discussion should be to stimulate, guide, keep up discussion, and end the exercise when time is up. 13. The trainer may wish to provide general feedback at the end of participant discussion. 14. Summarize the major points observed in the exercise and respond to participant questions with the entire group. PARTICIPANT HANDOUT 9C: ADOLESCENT AND YOUTH SEXUAL AND REPRODUCTIVE HEALTH ROLE PLAYS Role Play 1: A 19-year-old woman comes to the clinic because she had unprotected sex last night. She is worried about becoming pregnant. How will the clinician respond? Role Play 2: A 16-year-old woman with a three-month-old baby who is breastfeeding wants to postpone her next pregnancy. Her sister uses combined oral contraceptives (pills) and likes that method very much. She says she wants to use pills. How will the clinician respond? Role Play 3: A 17-year-old young man comes to the clinic because he is concerned about an itchy discharge from his penis. He reveals that he and his girlfriend are regularly having sex but are not using condoms. How will the clinician respond? Role Play 4: A young couple accompanied by the husbandÕs mother comes to see the clinician. The couple has been married three months. The mother-in-law insists that they should have a child Ð preferably a son -- as soon as possible. The young woman is still in school and appears to want to postpone pregnancy for at least two years. How will the clinician respond? Role Play 5: A 19-year-old young man comes for an HIV test. He reveals that he has both a female partner and a male partner, and that he regularly has unprotected sex with each of them. How will the clinician respond? Role Play 6: A 15-year-old unmarried adolescent girl with a physical disability comes to the clinic. She reveals that she is having sex with a boyfriend and she does not want to become pregnant. How will the clinician respond? Role Play 7: A 17-year-old young man comes for information. He is being pressured by his friends to have sex with his girlfriend. His girlfriend is also starting to say that he is not a real man because he wants to wait to have sex. He is worried about pregnancy, but he also has strong sexual feelings for her. How will the clinician respond? Role Play 8: A young couple comes to the clinic because the young man has a discharge and a burning sensation when he urinates. The young woman attends the clinic regularly to obtain injectable contraceptives, but says they are not using condoms because she is already using contraception. The clinician suspects that he may have gonorrhea or chlamydia. How will the clinician respond? Role Play 9: A 15-year-old woman with Down Syndrome comes to the clinic looking for information on contraception as she is planning to have sex with her boyfriend. How will the clinician respond? UNIT 9 SUMMARY TIME 20 minutes METHODS Feedback discussion MATERIALS NEEDED None STEPS 1. Ask participants to reflect on everything theyÕve discussed as part of this unit. In plenary, ask youth co-trainers to provide feedback to participants using the following questions: * Did this session and training accurately reflect the experiences of young people in seeking health services? Are there key differences that providers should be aware of? Anything specific related to the need of clients with disabilities? * What would you like to see change as a result of this training? 1 CART is a method to provide access to spoken communication for people with hearing, cognitive or learning disabilities. CART refers to the instant translation of the spoken word into text using a stenotype machine, notebook computer and real-time software. The text produced by the CART service can be displayed on an individualÕs computer monitor, projected onto a screen, or made available using other display systems. --------------- ------------------------------------------------------------ --------------- ------------------------------------------------------------ Module 16/Unit 7