Underserved populations are often marginalized and disproportionately affected by adverse health events. We create targeted interventions to ensure accessible and affordable health products and services reach these populations.
Today, there are over 1.8 billion young people between the ages of ten and 24 globally; 90% of them living in developing countries. Despite technological progress that has led to unprecedented opportunities for young people, significant barriers limit their access to crucial sexual and reproductive health information and services. These barriers include lack of knowledge and skills to access health services, unwelcoming and judgmental healthcare providers, restrictive policies that limit young people’s contraceptive choices and deep-rooted cultural and gender norms.
We are addressing these challenges through innovations in health service and product delivery, social and behavior change communication (SBCC) and addressing the social, economic, legal and cultural factors that make youth vulnerable.
Most health problems disproportionately affect the poor. We design strategies to ensure that products and services are available to them by providing subsidies, generating demand and improving availability.
Maternal mortality, or death during and immediately after childbirth, occurs much more often in low-income countries than in wealthy ones. Globally, over 12% of women want to prevent or delay pregnancy, but are not using any method of contraception. In low-income countries, this increases to an average of 22% of women, according to the World Health Organization (WHO).
Within countries, the difference is even starker. Ranking women by wealth within countries, studies have shown that for the poorest 20% of women in sub-Saharan Africa, only 31% of their need for contraception is met, while for the richest 20% of women in those same countries, 62% of their need is met.
Poor women have more trouble accessing family planning than their wealthier neighbors. Less access leads to early childbearing, more frequent births and unwanted pregnancy – all of which are related to increased risk of maternal death.
There is a global consensus that improving access to family planning is an imperative. We contribute to this important priority by socially marketing a range of high-quality family planning products and services in 51 low- and middle-income countries. We use approaches such as vouchers, mobile services, subsidies and information, education and communication tools to ensure that family planning is accessible and affordable for low-income women.
Female Sex Workers
Female sex workers are vulnerable to HIV infection and unintended pregnancies because of the frequency of sexual contacts, high numbers of sexual partners and their limited power to negotiate condom use and resist violent or coercive sex.
Given the context for female sex workers, our communication targeted to them emphasizes the importance of dual protection: encouraging them to use male or female condoms along with a modern contraceptive method in order to offer maximum protection against unintended pregnancies and STIs. Our solutions offer contraceptive and HIV services to female sex workers as part of an integrated package of sexual and reproductive healthcare in Madagascar, Cambodia, Ethiopia, El Salvador, Swaziland, Zimbabwe, Zambia, Benin, Togo, Cameroon, Malawi, and Mali. Read more about this integrated service work in Ethiopia.
PSI’s affiliate in El Salvador, PASMO, also integrates contraceptive and HIV services to better serve female sex workers. Read about the USAID-funded Combination Prevention Program for HIV.
About 70% of the world’s poor live in rural areas, where there are often fewer health workers, clinics, products and services. We believe in equal access to care for every woman, man and child regardless of income level or location. To help increase access to care, we expand the reach of contraception products and services to these hard-to-reach and underserved populations through mobile outreach services, special service events, task-shifting to lower level providers where possible and engaging community-based health workers. One example of this is our work in Guatemala’s rural Western Highlands, where we address the low health worker density by task sharing the insertion of long-acting reversible contraceptives (LARCs) with midwives. This creates greater access to a wider range of family planning methods for people living in rural areas.
Reaching postpartum women with reproductive health services is a critical component to decreasing maternal mortality and unmet need among women who want to limit or space their births.
In developing countries, the large majority of women do not want to have another child within their first year postpartum, yet there is a high unmet need for family planning. Waiting at least three years following a delivery to get pregnant again can significantly decrease the risk of adverse maternal and child health outcomes.
We strive to make it as easy as possible for women to receive health services at every stage in their life to ensure their own health and that of their children. Our programs integrate contraceptive services tailored to women’s needs into prenatal care visits, delivery, postnatal visits and immunization services, as well as post-abortion care visits whenever possible.
We also have programs in postpartum hemorrhage, the largest single cause of maternal death. Our network also promotes, distributes and trains providers in the safe use of Misoprostol, a drug effective in reducing postpartum bleeding.
Additionally, we train providers in postpartum IUD (PPIUD) insertion and removal for women seeking non-hormonal protection from pregnancy immediately following delivery.
Gender-Based Violence Survivors
According to the WHO, one in three women around the world has been beaten, coerced into sex or otherwise abused in her lifetime. Gender-based violence (GBV) is both a human rights issue and a major public health problem. Survivors are more likely to experience a wide range of health problems and unintended pregnancy.
While we promote couple communication about family planning, we recognize that not all women can safely raise the subject of contraception with their intimate partners. We aim to meet the diverse needs of clients, including those who do not disclose their use of contraception to their partner. Offering a wide range of voluntary family planning methods, including private, low-cost and long-acting methods, is critical to meeting those needs.
A number of our solutions also involve training healthcare providers to respond to cases of GBV with supportive counseling, sexual and reproductive health care and referrals for other services.
Male Partners and Couples
Many women wish to use contraception but do not do so because they think their partner would object. When couples talk about contraception, they are more likely to use it. Moreover, communication campaigns can increase couple communication about family planning and adoption of a contraceptive method.
In Zambia, we conducted formative research on the role of couple communication in family planning within the context of child marriages, and found that adolescent girls exposed to early marriage may benefit from more partner support from family planning. These findings are now being incorporated into programming in Zambia. Read more about our study on couple communication and family planning in Zambia.
We aim to engage men and women alike in joint decision-making about their reproductive health and childbearing. Our social marketing of family planning often includes messages and communication channels designed to reach men and couples. In Madagascar, for example, young peer educators gather groups of young men and women separately to discuss their family planning options. Read more about this work.
Making a Difference
We have developed extensive training and resources designed to help providers better engage and retain young people in care. In 2016, we published and disseminated From Innovation to Scale: Advancing the Sexual and Reproductive Health and Rights of Young People, which outlines ten components of PSI’s approach to advancing sexual and reproductive health and rights for young people.
In 2014, we developed Making Your Health Services Youth-Friendly, a guide to help providers assess their services, identify gaps and develop action plans that have been adapted from existing best practices. The guide provides an overview of the global need for youth-friendly service provision and offers key recommendations to develop and strengthen sexual and reproductive health services for youth.
We also conduct five-day training program for health providers that takes a participatory and applied learning approach to help them understand the context of youth and sexual and reproductive health in their own countries, as well as acquire basic knowledge of adolescent sexual and reproductive health development. The training features values exploration activities, case study discussions that disentangle personal from professional values, communication and counseling skills and site visits with practice using assessment tools. So far, we have trained health more than 1,200 providers in more than 20 countries.
Generating Demand for Youth-Friendly Services in Malawi
PSI/Malawi’s Youth Alert! is a multi-component social and behavior change communication (SBCC) program that links with youth-friendly health service delivery. A weekly radio program is written, produced and hosted by young people and broadcasted from PSI’s office in Lilongwe. The program addresses topics related to sex, sexual health, contraception and HIV prevention, often couched in broader discussions about other issues that attract young people such as relationships, finding jobs, academic success, music and popular culture.
Youth Alert! hosts work with a youth advisory board, engage youth through social media and travel monthly into communities, all in order to derive inspiration and ideas for the show directly from young people themselves. In conjunction with the weekly program, PSI/Malawi runs close to 600 listeners’ clubs around the country. These are small groups of young people that gather to listen to the radio program together and then engage in a facilitated discussion about the topic. PSI/Malawi holds launch events in communities to engage community gatekeepers including parents, so that they can learn about the listeners’ clubs and support the young people in their lives to attend. PSI/Malawi links these SBCC efforts directly with youth-friendly service delivery.
Many of the listeners’ clubs meet in the courtyards of private clinics within the Tunza social franchise. Tunza providers who received youth-friendly health services training and support welcome the listeners’ clubs and answer young people’s questions after the radio programs. In addition, PSI paints the Youth Alert! logo on the front of clinics that have been certified as youth-friendly so that young people can recognize them right away as safe, supportive and nonjudgmental clinics that will provide them with the SRHR services they need. In 2015, the Tunza franchise provided close to 20,000 family planning services for young people (15-24 years old) in Malawi.
Read more about the nationwide Youth Alert! campaign.
- Can Online Interventions Enhance HIV Case Finding and Linkages to Care? Comparing Offline and Online Monitoring Data from a Combination Prevention Program with MSM and Transgender Women in Central America (WEPEC166)
Under the USAID Combination Prevention Program for HIV in Guatemala, El Salvador, Honduras and Panama, the Pan American Social Marketing Organization (PASMO) implements offline and online interventions to increase HIV testing services (HTS) uptake among at-risk MSM and transgender women (TW), and link reactive cases to care.
- “Stigma And Discrimination-Free Zones”: An Innovative Approach to Engaging the Private and Public Sectors in Creating More Inclusive Environments for Key Populations in Central America (TUPED509)
Central America's HIV epidemic is concentrated in key populations (KPs). Despite existing HIV laws and policies that respond to KP's specific needs, there is evidence of widespread discriminatory attitudes and practices towards these populations, and stigma and discrimination continue to be important barriers to accessing HIV services and care. In 2016, under the USAID Combination Prevention Program for HIV in Central America, PASMO designed an intervention entitled “stigma and discrimination-free zones” as part of a broader initiative known as Generation Zero, contributing to the goal of “getting to zero discrimination.”
- Social Network Methods for HIV Case-Finding Among People Who Inject Drugs in Tajikistan (THSA16)
HIV testing programs have struggled to reach the most marginalized populations at risk for HIV. Social network methods such as respondent-driven sampling and peer-based active case-finding may be effective in overcoming barriers to reaching these populations. Under the USAID Central Asia HIV Flagship Project, we compared the client characteristics, yield, and number of new cases found through two RDS strategies and an ACF approach to HIV case-finding among people who inject drugs (PWID) in Tajikistan.
- HIV Care is Fine, But What if I Get the Flu? (THPED546)
In Guatemala, a concentrated epidemic within a highly stigmatizing social context creates an environment fraught with challenges for reaching, testing, and linking vulnerable men who have sex with men (MSM) and transgender women (TW) with HIV testing and care. PASMO commissioned an ethnographic study in 2016-2017 to understand the sexuality, identity construction, health care seeking behaviors, and MSM/TW-health provider relationships to design consumer-focused strategies to facilitate access to HIV services.
- Understanding the Uptake and Retention Patterns of PrEP Users in Zimbabwe by Sub Population (THPEC343)
PSI Zimbabwe has been offering PrEP as an additional HIV prevention method at New Start centers in six districts in Zimbabwe since August 2016. The New Start PrEP program is one of the demonstration projects that will help inform the national PrEP implementation plan to introduce PrEP nationwide as a new HIV prevention strategy. The primary target populations include adolescent girls and young women (AGYW) aged 15-24 years, female sex workers (FSWs), men who have sex with men (MSM), and serodiscordant couples.
- Sexual Practices of Men Who Have Sex with Men (MSM) in Madagascar (WEPED432)
MSM are a vulnerable population with a high prevalence of HIV (14.8%) and low HIV testing coverage (16.5%) in Madagascar. This study aims to examine barriers and motivation to HIV prevention, specifically on HIV testing, and condom and lubricant use among MSM in order to refine behavior change communication and programmatic strategies.
- Quadrupling HIV Case Finding: Social Media Improves HIV Testing and HIV Case Finding Among Key Populations in Myanmar (WEPEC169)
At PSI's TOP clinics serving key populations, there was consistently high HIV yield among peers using social media. Myanmar experienced a digital technology leapfrog. In January 2017, PSI invested in a dedicated social media team at TOP to responded to private messages (on Facebook, Line, Bee-talk, GRINDR and Viber), fielded hotline calls and offered online referral vouchers, which allowed us to track each conversation from online messaging to arrival at the clinic.
- Mapping Population Sizes and Hotspot Locations for Female Sex Workers Improved Targeting for HIV Prevention Interventions in Ethiopia (TUPEE702)
HIV prevalence among female sex workers (FSWs) in Ethiopia is approximately 23%. To address risk of HIV in this population, the MULU/MARPs combination HIV prevention project was launched in 2012 across 168 Ethiopian towns/cities. Implementation was challenged by insufficient data on FSW locations and sizes. A rapid size estimation approach was developed to aid program implementation.