2004 Bridges Summer Research Report Samantha Ehrlich School of Public Health "Investigating the Sexual & Reproductive Health of Adolescents in Bilwi, Puerto Cabezas, the North Atlantic Autonomous Region of Nicaragua"

The population of the North Atlantic Autonomous Region (RAAN) is extremely diverse, although it contains primarily people of indigenous Miskitu descent. The Miskitu are an ethnicity that is commonly discriminated against and often overlooked by the Government of Nicaragua, which contributes to the fact that the health care system of RAAN is not nearly as developed as that of Managua, the capital and largest city of Nicaragua. In addition, since most of the people of RAAN live in small, rural communities, much of the population remains out of reach of those services currently available. The largest municipality of RAAN is Puerto Cabezas, which includes the main city of Bilwi and its surrounding rural communities. The population of Bilwi is quite representative of the rest of RAAN, as most inhabitants are originally from the smaller, rural communities and have moved to Bilwi for work and/or educational opportunities.

While the rate of maternal mortality for Nicaragua as a whole is high, the rate of maternal mortality in the North Atlantic Autonomous Region is even higher. Florence Levy Wilson, previously the sub-director and later director of the Ministry of Health of RAAN, observed that a majority of the women dying in childbirth in region were young women and adolescents and that the adolescent pregnancy rate in RAAN was particularly high, at approximately 39 percent in 2003. Dr. Wilson concluded that improving the access to and use of contraceptives and reproductive health services among adolescents in the region would be an effective strategy to lowering the maternal mortality rate. Before an intervention could be initiated or changes made to the present system, the current state of access to, knowledge of and use of contraceptives among adolescents needed to be investigated. This investigation utilized both qualitative and quantitative methods to gather such information among adolescents in Bilwi, Puerto Cabezas, RAAN.

I completed both the qualitative and quantitative research portions of this investigation. I arrived in Bilwi with a rough list from Dr. Wilson of all the organizations and clinics working with and/or providing reproductive health services to adolescents and a letter to the current Minister of Health asking for support. Once I received permission from the Minister of Health in the form of official documentation, the leg work and the qualitative portion began. I walked all over town to contact the organizations on Florence’s list and by talking to those organizations, learned about the existence of others. Since many of these organizations were NGOs sympathetic to the plight of adolescents, everyone was extremely helpful, and I was able to conduct an interview with a representative from every clinic and organization working with adolescents and/or providing them with reproductive health services.

With information from these interviews and a few test groups of adolescents, I made changes to a draft questionnaire that had been previously designed with the help of a group of public health professionals in Managua. This created a culturally appropriate tool to complete the quantitative portion of the investigation. Using the contacts I had made conducting interviews, I was able to locate groups of adolescents to receive the questionnaire. A few organizations with contacts in the schools introduced me to various school directors and others provided the adolescents that their own organization worked with, and the quantitative data was collected. I was able to collect data on a diverse group of 550 adolescents, ages 10 to 18, in Bilwi through the schools, an art class and extracurricular sports activities, to name a few locations.

Before improvements in the voluntary use of modern, reversible contraceptive methods could be made among the adolescents of Bilwi, their current level of knowledge, their self-efficacy to use and their access to contraceptive methods needed to be investigated. This investigation will contribute valuable information to the Ministry of Health, the governing body of the region and local NGOs working with adolescents and highlight the type of changes and/or interventions that will be most successful in improving the situation. For example, before the investigators began, it was assumed that those adolescents currently using contraceptive methods received counselling and free methods at the local health clinics.

Preliminary analysis of the data indicates that more adolescents actually choose to go to their local pharmacy and pay for the methods. Therefore, an intervention that incorporates the local pharmacies with the promotion of contraceptives among adolescents appears to be more promising than one targeting the local health clinics. The investigators also previously assumed an intervention promoting sexual education in the schools would be quite effective. The many obstacles to providing such instruction in the schools became apparent throughout the qualitative portion of this study, indicating that other methods, such as utilizing extracurricular clubs or a radio program, would be more effective.

I am currently working towards a Masters of Public Health in Maternal and Child Health with a concentration in International Health. While this internship allowed me to put into practice what I have been studying this past year, it also gave me the opportunity to prove to myself that this type of work would be as fulfilling and engaging as I thought it would be. I have always been fascinated by reading about these topics but have never had the opportunity to become so directly involved in them. I had the opportunity to work quite independently on this project, and I was able to show myself that I could do it; I could go to a foreign country and put into practice the skills that I have been learning. I was able to use my knowledge of the field to collect valuable data and at the same time, I learned the necessity of patience, persistence, collaboration and sensitivity in community work, a lesson that can only be learned through experience.

This internship is just the beginning of my involvement in this field and will contribute greatly to my career goals. I plan to use the work I did this summer, along with the resources and guidance of professionals at the University of California, Berkeley and those in Managua, to write a complete analysis of the quantitative data collected and outline an intervention to improve the use of contraceptives among adolescents in Bilwi as part of an independent study class this spring. The connection I have made with the British NGO Health Unlimited will also be extremely valuable to me upon graduation and entry into the job market. This internship has provided me with the means of learning my chosen profession through practice and I hope to contribute too many similar projects throughout my career.