Review Findings [Review of Kam Pussum Hed (KPH) Clinic]

The key findings of the Review are presented under four sub-headings. Each subheading relates to the specific objectives of the Review. These include:

• The KPH Clinic Design
• Clinical Services and Clinic Operations
• Community Education and Outreach Programme
• The Peer Education Programme.

4.1 Review KPH Design

4.1.1 Background

As already mentioned, KPH Clinic evolved from community suggestions during the Blacksands Community Play to establish a Drop-in Centre to provide easy access to reproductive health information, counselling and services to the nearby communities of Blacksands, Tagabe and Manples. The suggestions arose as a result of increasing community awareness on health issues through plays and drama performances by Wan Smol Bag Theatre which has been conducting community awareness on health issues for more than 10 years in Vanuatu.

Kam Pussum Hed (KPH) Drop-in Centre was established towards the end of 1998 and was officially opened in February 1999 after a series of discussions and consultations between community stakeholders and the Department of Health. The agreement established that KPH Clinic would provide reproductive health services for the people of Blacksands and neighbouring communities, especially the young people, through community education, outreach services and clinical services. The main components of KPH were enlisted to include:

• A Reproductive Health Clinic called the KPH Clinic
• A Community Education Programme
• A KPH-based Educational Video Programme
• A Peer Education Programme

4.1.2 Stakeholders' Involvement

Department of Health

As soon as it became clear that Wan Smolbag Theatre was going to seriously look into the idea of opening a clinic, the Department of Health was approached. If WSB was to provide clinical services, obtaining the approval and support of the Department of Health was necessary. To this effect, a meeting was called and attended by WSB and key officers from the Department of Health. The Department was very supportive of this initiative and gave the approval for Wan Smolbag Theatre to operate a reproductive health clinic providing information and services to the communities of Blacksands and Tagabe. This support has continued and the KPH works closely with the Vila Central Hospital and the DOH.

At the meeting with the DOH, the decision was made not to register KPH as a dispensary. If KPH became a registered health dispensary, this would result in people from surrounding communities coming for consultations and treatment for minor ailments other than the services for which the clinic was designed for. This could mean that the people with genuine reproductive health concerns might not have the chance to access the necessary services, thus defeating the purpose of the clinic.

Communities

Following the approval by the DOH to establish a Drop-in centre, the next step was to determine the type of services to be offered and the management of the clinic and its staffing. This resulted in the whole cast of the Blacksands Community play (approximately 60 people) plus the Wan Smolbag Theatre members participating in a full morning of discussions on the nature of the clinic. In small same age/sex groups, the community had to answer the following questions:

1. What services should the centre provide?
2. What kinds of things would make you want to visit the proposed centre?

This led to a wide range of suggestions on the above questions. Some wanted expatriate nurses who would not know their families; for others it was important that the nurses be friendly and could be trusted to keep personal information confidential. Some wanted to be able to have delivery services at the clinic. There was a big discussion about whether the centre should charge a small fee. The men said that if it was a choice between paying 100vt for a bowl of kava and coming to the clinic, kava would win every time. This made the women very angry. They argued that paying for membership fees would give the community a feeling of ownership of the clinic and people would value the services more. In the end, it was decided that provision of services would not incur fees paid at KPH and this rule still applies today. At the end of this meeting, certain decisions were taken regarding the nature of the services to be offered at the clinic and how it was to be staffed.

Although it was not clearly documented, the understanding was that the clinic would be there for the purpose of ensuring that the target communities have access to information and services on reproductive health issues. It was hoped that this would ensure that the members of the community would develop better lifestyle choices in the areas of reproductive and sexual health through participatory workshops, outreach activities, and clinical services.

4.1.3 Target Population

The original idea was for KPH to be a Youth Drop-in Centre and to target young people. However, that did not mean that older members of the community could not use the clinic. In fact, people of all ages were encouraged to access the services provided by the KPH clinic. The main focus was that the people of Blacksands and the communities close to the centre would have access to the services that they could not access before. At the time of writing this report, the nurses reported that they attend to the needs of clients of all ages. In the area of family planning, most of those coming for consultation are older women who have had more than one child.

Although KPH Clinic targets young people of nearby communities as described above, services are offered to all age groups and to people from other communities. Interestingly, the fact that older people utilise the clinic has not deterred young people from seeking KPH clinic services. As a result, clinic utilisation has increased over the past three years and it is noted that service utilisation has exceeded the expectations of the original plan.

The Peer Education programme comprises a number of young men and women both from Efate and outer islands living in Port Vila. Peer educators go out to communities on a daily basis and provide information about reproductive health issues on a one-to-one or o group basis to their peers. Again, if older people were interested, the Peer Educators would talk to them as well. As will be seen in later parts of this report, the work of the Peer Educators has expanded over the years and the number of people they see each month has steadily increased. This has been largely due to increasing community coverage by peer educators.

4.1.4 Achievements and Issues

Achievements

The KPH Centre is attached to the back of the Wan Smolbag Haos at Tagabe Community, approximately six kilometers from the capital town of Port Vila. The location is a factor in making the centre accessible to young people and ensuring that they feel comfortable coming to the clinic. This is because Wan Smolbag Theatre has been working in the area of Reproductive Health for many years and the young people feel that coming to the clinic is similar to watching the WSB plays. It is also less conspicuous because it is at the back of the building. This location allows young people to go into the clinic without too many people noticing them. One of the hindering factors about established government facilities is that they are located in public places and young people are ashamed to be seen going to these places for fear of being spotted by others. On the other hand, KPH has the advantage of having a favourable location that assures young people of convenience and privacy.

KPH, as already mentioned, is one of only two clinics in the country that is an exclusively RH clinic. The other clinic is the Vanuatu Family Health Association, which is located in the middle of town. Because its services are focused to a specific clientele, the set-up makes it less crowded compared to normal health clinics. Another factor that makes KPH popular is the unique health facility model adopted at KPH - whereby an IEC component comprising the Peer Education Programme, the educational video, and the outreach programme - is balanced off by a wide range of clinic-based reproductive health services, all coordinated and based at the KPH. The community outreach programme facilitates a mechanism for advocating KPH services and establishes a referral link between communities and the clinic. The complementarities offered by the IEC programme and the clinic-based services make KPH the ideal model for providing reproductive health services.

Issues

When the clinic was set up, the target population was the young people of the communities of Blacksands and Tagabe. The original setting was adequate for this target population. However, KPH has grown over the last three years – increased numbers of clients are using the clinic services while greater community coverage has been achieved under the outreach programme and the peer education programme. These increases in demands for services and programme expansion were not anticipated. KPH is now serving clients from as far away as Pango and Erakor and is also serving clients of all ages. This picture paints the rationale for proposing that KPH should redesign its clinic programmes and services to meet the needs of its increasing clientele. It is therefore necessary to expand KPH based on increases in the use of KPH services and to offer RH services to all age groups in communities.

4.2 The Clinical Service and Operations

Established in February 1999, KPH Clinic provides a number of clinic-based reproductive health services including counselling. According to clinic data, the most common clinical services provided are contraception and family planning, treatment of sexually transmitted infections (STIs), and reproductive health counselling. Although counselling crosscuts into both family planning and STI services, the data on counselling does not specify the types of cases being counselled; however, KPH staff described counselling sessions to be related to different aspects of reproductive health such as pregnancy, contraception and safe sex practices. All services at KPH are free to the public. While the focus of KPH is to serve young people 25 years and below, it has also been a convenient service outlet for older age groups as well, particularly those living close to the clinic, especially communities of Blacksands, Manples and Tagabe.

4.2.1 Clinic Load and Utilisation

Three nurses (2 females and 1 male) work at KPH Clinic to conduct the daily clinics. They also work in rotation to undertake the community outreach education programmes by holding community-based reproductive health seminars and workshops. The longest-serving nurse has been working since the establishment of KPH in November 1998. She is the nurse-in-charge of KPH and is responsible for the day-to-day management of clinic activities. The overall management of KPH is under the Director of Wan Smol Bag Theatre until six months ago when it shifted to the responsibility of a newly created position of a second Research Officer within Wan Smol Bag.

The other two nurses joined KPH over the last two years. One of them has had clinical experiences working in hospital wards while the other, at the time of appointment, was a recent graduate from the Vanuatu Centre for Nurse Education (VCNE). The nurses work in rotation to cover the clinic daily schedules and to conduct community education outreach work running workshops and meetings with communities. They also provide support and guidance to the peer educators in matters related to their outreach peer education work.

According to clinic data, the monthly clinic load at KPH averages 200-230 cases per month. During the period January – June 2002, the total monthly case load ranged from 175 – 236 per month. During this six-month period, the main features of clinic cases are as follows:

The most common types of cases are family planning services, treatment and follow up of STI cases and counselling in reproductive health. Other types of services provided at KPH include pregnancy testing, emergency contraception, counselling on infertility cases, consultation for minor ailments such as flu, and hospital referrals for further client management.

4.2.2 Contraceptive Services

Contraceptives available at KPH Clinic include Depo Provera, family planning pills and condoms. These are supplied by the government health department at no cost to KPH. Pills are available in both combined form and progesterone-only pills (mini-pills). Emergency contraceptive pills (ECP) are also available but are not frequently used and this is likely due to the lack of awareness and knowledge among target groups and potential users. Lack of community awareness is in turn linked to the lack of dissemination of ECP information and a reflection of inadequate promotion by the programme. The use of ECP varies from 0 – 3 cases per month during the period January-June 2002.

The average number of new family planning users in KPH is around 30 per month while revisits average around 60-70 a month. Depo Provera is the most popular method of contraception used. The use of intra-uterine device (IUD) is not available at KPH because facilities required for IUD insertion are not available and clinic nurses have not been trained in IUD insertion. However, nurses expressed the need to introduce IUD insertion as a contraceptive option because of its many advantages, especially its long-acting feature.

Although clients of all ages visit KPH for family planning services, a large proportion comprises young people below age 24 years. During Jan-June 2002, clinic records show that about half of family planning clients are below 24 years of age. In all age groups, female clinic attendance for family planning services far exceeds that for male, with a ratio of 5:1. A large proportion of KPH clinic attendants go to the clinic only to seek information and counselling related to family planning. They are interested to discuss their circumstances with the clinic nurses and seek their advice. Contraceptive use among young girls below age 19 years is not uncommon, most of them have steady partners. Since there is no family planning policy, contraceptives are given to young girls if they are sexually active and express the need for contraception.

4.2.3 Treatment of Sexually Transmitted Infections (STIs)

KPH Clinic offers services for the treatment of STIs using the "Syndromic Approach" of STI management. Only one of the three nurses has been trained in STI management under this regime through an in-service training organised by the Department of Health five years ago. She has then trained the other two nurses through an on-the-job training. Under the syndromic approach, a standard treatment regime similar to the one used by the Vila Central Hospital is being used.

As a standard approach to the management of STIs, all patients presenting with a discharge undergo a clinical examination and specimen taking followed by drug therapy under the established protocol for the treatment of STIs in Vanuatu. The average number of new STI cases in KPH is around 40 per month while revisits and follow-up cases are generally lower than new cases and average fewer than 10 a month. This indicates that cases that have received treatment do not return for follow up. This is something that KPH might wish to improve upon because patient follow up using the syndromic approach is crucially important for post-treatment counselling, partner treatment, and to discuss safe sex practices and prevention of re-infection.

Contact tracing can be difficult because it is not often that clients disclose partner details; and even if they do, partners do not always turn up for assessment and treatment. This is an area that needs to be addressed because of the high rates of re-infection and further new infection caused by untreated asymptomatic partners. Hence, the importance of building rapporteur with clients during the post treatment follow-up session.

4.2.4 Clinical Skills of Providers

The nurses were dedicated and committed to their work in the provision of a range of reproductive health services. They expressed satisfactory technical knowledge of the major clinical conditions they attend to – family planning & contraceptives and treatment of STIs. There is evidence of transfer of knowledge and skills within the nursing clinic staff. However, it was noted through direct observation of service providers that certain clinical skills need to be improved – such as thorough history-taking and clinical examination. For reference and follow-up purposes, perhaps a patient card is more informative than a clinic logbook. Up-to-date clinical skills have an impact on the quality of services provided. The use of standard guidelines or protocols and a checklist for taking client history and undertaking a medical examination would help to improve the quality of care in reproductive health services provided.

In some cases, essential elements in the history required to carry out an STI/pregnancy risk assessment, are not addressed. In order to obtain a full history it is essential to develop standard questions in the checklist. This helps to identify risk factors in a person's lifestyle, which then provide the basis for counselling. Equally important is a checklist for carrying out standard clinical examinations. However caution needs to be taken so that medical examinations do not unnecessarily compromise easy access to services. Pelvic examination should have standard guidelines procedures. The small space in the clinic set-up was observed as a limiting factor in facilitating the conduct of a full examination that meets clinical standards. Privacy was also compromised because of limited clinic space and its close proximity to the video room.

Although nurses felt confident with the way they counselled clients, counselling skills in some of the clinic staff can be improved. Certain key elements of basic counselling were not addressed in some cases observed. Quality counselling is essential in aiming to provide client-friendly services and it also helps to ensure that client follow-up is maintained.

The concept of "integrated approach" in reproductive health can be discussed in staff meetings so that when clients attend clinics for a particular condition, other reproductive health issues are addressed. For example, an STI case may also receive counselling on contraception and vice versa. The approach helps nurses to establish a reproductive health profile of clients who visit the clinic. The use of checklists and clinical guidelines will facilitate the process, as already mentioned.

4.2.5 Case Referrals

Cases requiring further clinical assessment and management are referred to the Vila Central Hospital to be seen by the hospital-based gynaecologist. However, referral mechanisms for ensuring that clients have confirmed clinic appointments should be strengthened. This will also facilitate continuity of care, particularly for female clients.

In some situations, the visit to the hospital does not always end at the doctor's clinic because clients may not be sure of where to go. Hence written referrals reinforced by telephone communications with the hospital are more effective than verbal referral. In the past, the nurses make written referrals and liaise with a volunteer doctor at the hospital who would then refer KPH patients to the specialist in the hospital. This has stopped since the volunteer doctor left. The nurses feel that this system was effective and the mechanism should be maintained. Perhaps another key person at the hospital be identified to replace the link previously developed with the UNV doctor.

4.2.6 Staff Training Needs

Only one of the nurses has attended an RH counselling workshop organised by SPC in collaboration with Health Department in 2001. Nurses expressed the need to undergo refresher training in reproductive health, family planning, counselling techniques and to learn new procedures such as IUD insertion and PAP smear procedures. The need for training in Clinic management and Supervision was also expressed.

Records of clinical consultations are entered into a consultation logbook. This information may or may not be stored as a database file. However, a computer printout of monthly clinic operations was made available during the review exercise. Such wealth of information can be used for learning purposes in reviewing and monitoring clinic operations. It can also be used for case discussion on client management reviews and for lessons learnt. There is a need for in-service training to address how to manage data, understand data and use data for monitoring and planning purposes.

4.2.7 Supplies and Logistic Management

The day-to-day operations of the KPH clinic is under the responsibility of the Nurse in-charge while the overall management comes under the management responsibility of the Research Officer of WSB who finally reports to the WSB Director.

Medical supplies, including contraceptives and medicines for treatment of STIs, are supplied by the Government Pharmacy at no cost to KPH. Orders are made every quarter and it takes an average of two weeks to receive the supplies. The system seems to be working well although there have been some unavoidable incidents of stock-outs. The client impact is that they either change their contraceptive method or they get referred elsewhere. However, stock-outs do not occur frequently, except that there was an acute shortage of condoms at the time of the Review. In this situation, there seems to be some hesitation on the part of the Health Department to come to the rescue of condom stock-out. Under the circumstances, KPH resorted to purchasing condoms from a private supplier in order to meet the needs of its clients.

There has been some concern regarding the rapid utilisation of condom supplies of 12 boxes a week supplied by the Department of Health. Queries arose as to whether these condoms, regularly distributed by peer educators, are being targeted at the young populations, whether they are actually being used for contraception and/or STI prevention, and whether there are possibilities of abuse. Although KPH staff felt strongly that condoms have been used purposefully, it would be useful that distribution records are accurately documented so that in the long run it would be possible to determine condom utilisation patterns and to forecast accurate requirements in the procurement process.

4.2.8 Clinic Facilities

The clinic comprises a single room measuring approximately 3 meters x 3.4 metes. Adjacent to the clinic is a larger room that provides educational video viewing for young people and anyone who is interested. Both rooms have a common entrance door. There is another door to the consultation room, in front of which is a desk for the Administration Officer which also accommodates the clinic computer. Clients do not have a waiting room and therefore have to hang around outside the clinic or wait at the adjacent video room before being called into the clinic. There is no reception area in the clinic. The one-room small clinic space is used for all clinic-related activities – client consultation, counselling, examination, storage, cleaning of instruments, specimen-taking, data recording, etc. Provider ability to provide quality services is compromised by the limitation in the clinic space, clinic set-up and limited facilities. The current set-up makes it difficult for nurses to provide quality services and maintain clinic standards in relation to hygienic procedures, client flow and privacy.

Both clinic nurses and clients felt that having the clinic separated from the video room would provide more space for better clinic services. It will ensure better approach to clients, promote confidentiality and privacy and benefit both the provider and clinic users.

4.3 Review of the Community Education and Outreach Programme

The community education and outreach programme of KPH Centre comprises community educational workshops, orientation bus trips to KPH Clinic and educational video shows. These activities complement each other to create greater awareness about the services offered at KPH and to build further knowledge on different aspects of reproductive health. It is through these programmes and through the peer education programme that more people get to know about the services provided at the KPH Clinic. Increasing clinic utilisation has largely been the result of advocacy work, community outreach activities and word by mouth from satisfied users.

4.3.1 Community Workshops

The KPH nurses work in rotation to concurrently cover the daily clinics and also conduct educational workshops in selected communities. A striking feature of this programme is that the same nurses who run the clinics at KPH also conduct the community workshops. They are able to do this through the assistance given by peer educators who help to organise the logistics of the meetings. Community feedback about these workshops has been positive and many expressed that they would like to attend more of these meetings to discuss reproductive health issues. Of those who were interviewed or participated in focus groups discussions, the responses included the following quotes:

• Heard of KPH Clinic by attending the community workshops.
• KPH provides family planning services and treatment of STIs.
• Community programmes of KPH have been helpful to share information on reproductive health, HIV & AIDS, STIs and youth concerns.
• We are aware of peer education outreach programme.
• We find KPH clinic useful – we suggest that another KPH clinic is established in another location in town.
• We need more community-based workshops – in each village youth must be targeted.
• It would be nice if some video shows are also shown during the workshop – this will make the sessions interesting and the video will also attract youth to attend the workshops.
• The workshops should involve the chiefs and religious leaders – the village people listen to these people.
• Fear/concerns – Some were concerned about too many people hanging around KPH. The crowded scene has in some cases deterred people from coming into the clinic.

>While the communities generally value and enjoy attending the community workshops, nurses sometimes face difficulties and challenges in reaching out to communities. Some of the difficulties include:

• Logistic difficulties to reach some communities, particularly during unfavourable weather,
• Some people are not interested to attend the workshops resulting in poor turn-out in some workshops,
• The lack of adequate IEC materials to facilitate discussions,
• Workshop coverage does not reach out to all villages and settlements and there are community concerns regarding this.

4.3.2 KPH Familiarisation Bus Trips

As a promotional activity for KPH services, orientation bus trips are organised to take groups of community men, women, youth, and students at different times and schedules to visit KPH Clinic. The exposure and orientation aim to familiarise target groups with KPH services, increase awareness about reproductive health issues, and how people can access KPH services. Feed back from people who have participated in these bus-trips is encouraging and they recommend it to others who do not know about KPH Clinic. However, one of the difficulties encountered in these bus-trips is that when a busload of people arrive KPH, there are limited meeting room facilities to run workshops, presentations, and discussions which would add value to the orientation programme. There are also concerns among some that the selection of communities and schools who participate in the bus trips may happen on an ad hoc basis rather than a planned yearly schedule. The teachers of a particular school suggested that it might be better to involve senior students (above 15 years) as this would be more appropriate for them than for year six students (10-12 years) who are too young to conceptualise as to why such bus trips are made at early stages of their lives. The focus on involving older students is already being incorporated as part of other activities undertaken by the KPH clinic and Wan Smolbag Theatre. Teachers also expressed interest to be part of the orientation programme if their students are taking part. They felt that their involvement would help to follow up with students some of the issues discussed during the orientation programme.

In any case, the bus trips have increased reproductive health awareness and knowledge about KPH services, more so in adult population than in young students. Some people would participate in another orientation programme if given the opportunity.

4.3.3 The Educational Video Programme

To provide another dimension of IEC source in supplementing outreach community education, the KPH Centre offers daily video showing at its video room located adjacently to the Clinic. Supervised by the Clinic nurses, the video sessions run throughout the day side by side with the clinic operations. Video tapes on various reproductive health issues such as pregnancy, family planning, STIs, HIV/AIDS, domestic violence and other related topics are viewed on a daily basis.

The video sessions are generally popular and rated highly useful by past users who stated that the approach was a relaxing way of obtaining information. However, certain concerns regarding the video sessions were raised during the review - these include the following:

• The location of the video room side by side to the clinic room has raised concerns among staff of KPH, clients using the clinic and video viewers. A lot of video viewers take up space and create noise around the clinic environment.
• It has become a common statement among KPH staff and clinic users that the Clinic space is too small to ensure privacy and comfort for clients and providers.
• Clinic clients are put off by the overcrowding of KPH facilities which sometimes interferes with clinic privacy and conversation with nurses.
• In one room many things are located: the video room, the clinic, library, Administrator's desk. In the midst of this, people pop in and out, clinic clients try to see the nurse, video viewers trying to get empty seats, and staff of KPH trying to do their work. The whole place becomes hot and stuffy – a danger to health standards and to clinic operations. Hence, there were suggestions that the video room and the clinic should be separated.
• Some concerns were raised as to whether there is potential for the video room to be regarded as an entertainment centre rather than a source of educational information on reproductive health. This is because it is open throughout the day and different age groups flow in and out as they please. Appropriateness of video showing for an audience of extreme age differences was also a concern. In this regard, suggestions were made that the video sessions should have structured schedules so that there is some organisation of sessions, instill a sense of value among viewers and minimise potentials for treating the video educational facilities as an entertainment centre.
• To maximise the usefulness of the video shows, staff of KPH could provide an introductory overview of the video show prior to viewing. In addition, a summary of the key messages should also be provided at the end of each show. Thereafter, a KPH facilitator could generate some discussions so that viewers can relate the video messages to real life situations. A client said, "Video shows would be more useful – if someone explains the meaning of the show --- explain before the beginning of the show and at the end of the show".

However, even though the video room is always crowded and noisy, it is this informal atmosphere where people are not on attention that some clients prefer. They come into the video room on the guise of watching a video and would then slip into the consultation room when they feel comfortable enough and are not afraid of being noticed. Thus a balance has to be maintained in ensuring that this aspect of KPH, its easy access, is not compromised in efforts to expand the facilities.

4.4 Review of the Peer Education Programme

The Peer Education programme is an important advocacy/IEC component of the KPH Centre. The main purpose of the programme is to provide information and education to other peers or to any interested persons, on a one-to-one or group approach through community outreach. It comprises seven trained Peer Educators – 4 males and 3 females. They have been working for KPH for the past 2 – 3 years. All of them have undertaken the 2-week training course for Peer Educators run by AIDS Task Force of Fiji in July 1999. This has been the only peer education training that they have attended. The training actually marked the beginning for the Peer Education Programme in KPH. Two of the female peer educators have further built capacity and confidence through attending an HIV peer education training in Fiji through the Fiji AIDS Task Force in 2000. Some of the peer educators come from outer islands and have been living in Port Vila. In general, peer educators enjoy working as peer educators, although they realise that their work is challenging.

4.4.1 Work Programme

The peer educators meet every Friday to discuss their outreach work over the past week and share experiences. They then discuss and agree to a work schedule for the following week. The worksheet is submitted to the Administrator who works out their bus-fares support based on the communities to be covered in the coming week. The peer outreach programme aims to reinforce awareness messages created by the WSB theatre group. Following theatre activities in the communities, the peers would then discuss the issues with communities on a one-to-one basis or to groups of young people.

The peer educators also assist the community outreach workshops run by the nurses. They are assigned in rotation of 3 peer educators for every community seminar or workshop. Most of the villages in Efate have been covered or visited by the Peer Education Programme. However, it was noted that some of the villages have been revisited more than the others. There has also been the tendency for the same groups of people to be repeatedly visited rather than peer educators reaching out to new groups who have never had previous contacts with them. This reflects the need for peer educators to discuss their difficulties and identify approaches of how to deal with situations that are challenging.

The peer educators are confident in providing information to peers regarding growing up and developmental changes, STIs and prevention of teenage pregnancy. Working in pairs has helped them to deal with some of the difficult situations. There are weekly meetings with clinic nurses and also with KPH management as the need arises. Nurses regard Peer Educators as useful people – they do community outreach and help organise community workshops. It is through the Peer Educators that many clients hear about KPH services and decide to seek services at KPH.

4.4.2 Community Perception about Peer Educators through FGD

A number of focus group discussions (FGDs) were conducted for different groups to obtain feedback on how the peer educators are perceived among communities. In general, communities feel that the work of the peer educators is useful and should be continued. Some of the feedback statements were as follows:

• I was influenced by the work of Peer Educators who provide information about reproductive health and promoted the use of KPH services.
• I attended the KPH peer education meetings to learn more about family planning and reproductive health.
• KPH workshops are good – we need more of them. Peer educators are good – we need to continue doing peer education.
• Peer educators need to go more frequently to schools and to other communities that they have not previously covered. Some difficult areas are not covered.
• Peer educators are doing a good job in communities talking about difficult subjects.
• We want to see more Peer educators coming to our communities. Sometimes they keep on going to the same places while others do not have the opportunity to have peer education.
• More new video tapes to be shown in communities when nurses and peer educators come to do the community workshops.
• Need to expand another KPH model to other parts of the country.
• Special features that make KPH special – away from town, free, short waiting time, specific for RH services, and convenient location.

4.4.3 Difficulties Faced by Peer Educators

Although peer educators feel good about their work and are rated high both by nurses and communities, the Review identified some concerns and difficulties that need to be addressed to further strengthen the work of the peer educators. The main ones include the following:

1. Female peer educators face the challenge of providing information to boys or a group of boys – sometimes the peer educators and their messages are not taken seriously. They are also sometimes teased as "condom distributors".

2. Being familiar with communities can affect the interest of the target population. They sometimes prefer to see a new person who does not know them. Peers have to consciously play a role model for young people if they were to gain the respect of their peers.

- Occasionally, there is a reaction from Church or Chiefs about use of church halls for community meetings to discuss STI/HIV/AIDS.

- KPH is sometimes regarded as Information Centre for youth information and a place for flu medicine, consultation, a check-up place, FP and STI clinic.

3. Discussing issues related to use of condoms and sexual activities.

4. Talking about condoms and carrying condoms is a challenge- especially among girls.

5. There has been no organised on-going training or meeting where peer educators discuss their work progress, issues encountered, difficulties in outreach work, etc. Nurses do help them in technical information about reproductive health but not consistently. They generally do not discuss their concerns with a specific supervisor as they are not sure as to who is responsible for this.

6. There is no clearly defined mechanism for the Peer Educator programme linking up with the theatre group.

7. Peer Educators need support and recognition of the work they do. A supervisor that oversees their programme and looks into their needs is required.

8. The video room needs some urgent improvements – space, separate video room, clinic organisation, waiting-room, separate doors to video, administration and clinic room.

9. A clear signpost for KPH Clinic to indicate that the clinic is for young people – opening times and what services are provided. Open/Close sign on door. Advertise KPH services more.

10. The peers observed that some clients make personal preferences to nurse. Nurses ae nicer to people they know – not to everyone.