By Kristely Bastien, Former Youth Technical Advisor for PSI Côte d’Ivoire
“No one ever talks to us about this,” Noelle signed, pointing to an IUD on display.
For Noelle, like the 15 deaf students in her class, this was the first time that sex ed was offered in school. And it would be the last time for now that she’d be in school as COVID-19 forced school closures and the government enforced social distancing measures.
In Côte d’Ivoire, six in 10 girls aged 15-24 want, but do not have access to modern contraception, and more than four in five girls will have a baby by the age of 25. According to the WHO’s 2011 World Disability Report, in the Ivoirian population as a whole, for every 100 person years, 13.8 are lost to disability.
Research in West Africa shows that while young people living with a disability face higher barriers than their peers when it comes to accessing sexual and reproductive health (SRH) services and information, serving this population does not require a radical transformation to respond to their specific and wholly addressable needs. In fact, addressing the needs of differently abled populations can often be achieved through practical and cost-effective modifications to existing programs. Service providers must expand their scopes to consider and adapt to young people’s broad spectrum of needs, regardless of abilities.
Youth with disabilities cannot be overlooked.
Through combined funding from the Dutch Ministry of Foreign Affairs and PSI’s Maverick Collective, PSI Côte d’Ivoire launched a pilot with the National Association of the Deaf of Cote d’Ivoire, aimed at deepening the evidence base around reaching and adapting youth-friendly SRH services for deaf people aged 15-24.
Read on to see how PSI Côte d’Ivoire ensures sustainability through the Ministry of Health to ensure the learning from this could serve a wider purpose/impact.
Delivering for People with Hearing Disabilities (and lessons that can be applied to serving all differently abled populations)
In early 2020, PSI Côte d’Ivoire worked with the only deaf School in Yopougon (a district of Abidjan) to pilot an SRH curriculum. Implementation was led by pairs of deaf interpersonal communication (IPC) agents known as “Big Sisters.” Big Sisters are accompanied by two sign language interpreters who help communications between the Deaf audience members and the hearing youth-friendly midwife, who is there to provide guidance and answer medical or technical questions.
That was, until COVID-19 emerged.
By March 2020, PSI Côte d’Ivoire had adapted its approach in response to the pandemic. Alongside veteran (non-deaf) IPC agents, newly trained deaf Big Sisters and sign language interpreters engage deaf young people either individually or in small groups of up to five people, while respecting physical distancing guidance.
Over a six-month period, PSI Côte d’Ivoire and its deaf partners:
- Reassessed the SRH curriculum through the lens and perspective of six deaf women
- Held a five-part workshop series to adapt SRH tools to the needs of deaf clients
- Partnered with the Society without Barriers-Côte d’Ivoire, a local organization that provides sign language interpreters
- Supported a team from the London School of Economics (LSE) to finalize qualitative research on SRH and disabilities in francophone West Africa on SRH and disabilities in francophone West Africa
- Hired four deaf women to lead sexual education conversations, which reached 64 deaf girls in the Following these conversations and two mobile service events, 49 deaf women voluntarily chose a contraceptive method.
- Met with Ministry of Health representatives to ensure pilot learnings could serve a wider purpose/have a greater impact/encourage other orgs to take steps to be more accessible to all youth of different abilities
- Invited representatives from the Association of Parents of Deaf Children to a meeting with the Ministry of Health and Education to share accessibility concerns and to provide input for a parent and reproductive health focused guidebook
Based on our experience – drawn both from the project’s early technical learnings coupled with our own anecdotal observations: what did we learn that you too can adapt? And what more do we need to keep the momentum going?
1. Develop and tailor solutions with the deaf community.
PSI Côte d’Ivoire continuously course corrected in partnership with the deaf community members throughout the pilot.
Based on our experience, suggested adaptations include:
- limiting the number of participants (when classes are held at school) to reduce “side signed” conversations between students. Because the deaf students are using their hands and eyes to have these side conversations, they are not able to also give their attention to the SRH content or the Big Sister;
- hiring two interpreters per session to share translation responsibilities;
- providing tangible objects like anatomical models or samples of contraceptive methods for the youth to feel and examine; and
- using digital media, like Facebook, to reach the deaf outside of physical settings with real-time trusted SRH information through videos and posts.
Serving deaf youth requires adapting programming (e.g., bringing in an interpreter) to serve young people–regardless of abilities. At the same time, we understand that we must be cognizant of how many words are used instead of images; ensuring that interpreters are present at events, and that the deaf have access to seating in an area where they can easily see the interpreter.
2. Generate demand responsibly- and link deaf youth to services.
Increasing knowledge and demand for contraception does not sufficiently address the full journey of any girl, including a deaf girl: from when she goes to a clinic and chances are no one can understand her, to when providers will not serve her because they cannot communicate with her, to when she has follow-up questions (or needs continuity of care), but has trouble meeting these needs.
It is important to allow youth the space to actively communicate their concerns with someone that is fluent in their method of communication. As a result, the deaf lead demand generation for their deaf peers in the community. But how might their scope be expanded to accompany young deaf people seeking clinic services?
PSI Côte d’Ivoire worked with the Ministry of Health to determine how best to support deaf youth; for example, by linking them to a trained interpreter who can communicate their needs and questions at the clinic and/or relay sensitive information from the provider to the young person. PSI Côte d’Ivoire is also piloting special event days when interpreters are available at specific YFHS clinics or at PSI Côte d’Ivoire mobile services.
3. Communicate visually (a best practice for all, especially when communicating with illiterate populations).
Service providers must meet young deaf people where they are at—and with the requisite hands-on tools and support, such as interpreters, to engage them in responding to their needs.
As one of the primary activities, representatives of the Association of the Deaf of Côte d’Ivoire, pilot participants, and PSI Côte d’Ivoire jointly adapted a visual flipbook (with limited text) to reach those deaf young people who are also illiterate—the literacy rate of 15-24 year old’s in Côte d’Ivoire is 58%. PSI Côte d’Ivoire used the flipbook to initiate SRH conversations; the deaf suggested and approved modifications—every image included tells a story intended to complement the sign language interpretation, or can even be interpreted without assistance or significant context.
4. Conduct comprehensive training for all stakeholders.
In addition to an interpreter, two deaf persons relay messages between deaf youth, the interpreter and the hearing medical provider. This element is crucial given the nuances of signing, such as the order in which to sign the concepts in a message. For example, PSI Côte d’Ivoire had challenges when non-SRH trained interpreters first signed the French word “sterile” for “IUD.” Without the deaf interlocutor with knowledge of the SRH context, young deaf people thought the hearing IPC agent was suggesting that they get sterilized.
To ensure that nothing gets lost in translation, every frontline staff member–from interpreters to mobilizers–needs a thorough understanding of the content presented. PSI Côte d’Ivoire ensured that the deaf IPC agents leading demand generation were trained in the SRH curriculum as well as Youth Friendly Health Services (YFHS). Just as in any language, understanding technical content can improve and/or inform the interpretation.
Furthermore, using insights from deaf young people and interpreters gained during the trainings and the human-centered design process, PSI Côte d’Ivoire and its collaborators worked extensively to determine the best order to sign each section of the SRH curriculum to not only improve understanding and retention, but to also encourage open dialogue on a culturally taboo topic.
It’s a positive youth development best practice: to truly catalyze impact at scale, more inclusion is needed–and to get there, partnerships are important. That includes partnerships with the deaf, too.
In addition, improving the enabling environment involves engaging the influencers who can champion adaptive programming to improve access among the deaf community. To this end, PSI Côte d’Ivoire has worked closely with the president of the Association of Parents of Deaf Children and the Ministry of Health, and partnered with local disability organizations, including Society without Barriers and the National Ivorian Association of the Deaf. PSI Côte d’Ivoire intentionally trained role models whose messages would resonate with the deaf community, such as the President of Deaf Women in Abidjan and the 2019 “Miss Handicap” winner (who happened to be deaf) as “Big Sisters” to advocate for SRH program integration within their community. PSI Côte d’Ivoire has also partnered with parents of deaf children, training them as mobilizers to do outreach for deaf youth and their parents.
PSI Côte d’Ivoire has already partnered with LSE to prepare research on integration of SRH needs among youth with disabilities in West Africa, and has created opportunities for diverse stakeholders, from the Ministry of Health to community members, to collaborate in adapting programming. Throughout the pilot, PSI Côte d’Ivoire has invited multiple deaf associations to planning meetings to ensure that representatives of the Deaf community are involved in programmatic decisions across PSI Côte d’Ivoire’s youth programs. PSI Côte d’Ivoire has also set up disability and accessibility trainings for both PSI Côte d’Ivoire staff and local partners.
It is recognized around the world that the best solutions for adolescent-responsive programming come from young people who have a seat at the decision-making table. This may in fact be even more important as PSI expands service provision to account for the needs of deaf adolescent girls and young women.
Serving the deaf community is neither a case study nor a pilot. Closing the gap in young people’s unmet need for contraception means serving all youth–their varying identities, their unique desires, and their abilities, no matter the form—the deaf included.