J Kedokter Trisakti

Januari-April 2002, Vol.21 No.1

Stakeholder perception on adolescent reproductive health clinics Nugroho Abikusno Center for Community Health and Population Studies Trisakti University Research Institute Jakarta ABSTRACT This study assessed stakeholder perception on adolescent reproductive health clinics in Indonesia. A series of stakeholder specific focus group discussions were held in a randomly selected sub-district in south Jakarta and informants (n=30) were taken from the community related to a senior high school in its vicinity. Each group was requested to provide their comments on several themes related to the existence of an adolescent reproductive health (ARH) clinic in their community. Stakeholders were mostly female, Javanese, Muslim, and had intermediate education. Most of the stakeholders did not know that an ARH clinic was available in their community. Major source of RH information of stakeholders was from other peers. Most of the stakeholders felt ashamed to discuss sexual matters in the community. Family support was considered by all of the stakeholders as a major factor influencing quality of ARH services. We recommend that the ARH clinic be more proactive in communicating their ARH service to the community. In our case there is potential for peer educator recruitment and peer group development in particular for parents. Key words: Reproductive health, adolescent, stakeholder, perception, Indonesia

ABSTRAK Tujuan penelitian adalah menilai persepsi para stakeholder tentangtentang klinik kesehatan reproduksi remaja (KRR) di Indonesia. Rangkaian focus group discussion dengan berbagai kelompok stakeholder diadakan di suatu kelurahan di Jakarta Selatan yang dipilih secara acak dan informan (n=30) diambil dari suatu komunitas sekeliling suatu sekolah menengah atas. Setiap kelompok melakukan diskusi tentang beberapa tema yang berhubungan dengan keberadaan klinik KRR di lingkungannya. Para stakeholder umumnya perempuan, suku Jawa, dan pendidikan sekolah menengah. Kebanyakan stakeholder tidak mengetahui adanya klinik KRR di lingkungannya. Sumber informasi tentang KRR diperoleh dari teman sebaya. Kebanyakan stakeholder merasa malu membicarakan masalah seksual secara terbuka. Dukungan keluarga dianggap semua stakeholder sebagai faktor utama yang mempengaruhi kualitas pelayanan KRR. Disarankan agar klinik KRR lebih proaktif menginformasikan keberadaan pelayanan KRR di lingkungannya. Dalam penelitian ini terdapat potensi untuk mengembangkan kelompok sebaya terutama di kalangan orang tua. Kata kunci : Kesehatan reproduksi, remaja, stakeholder, persepsi, Indonesia

INTRODUCTION In newly democratizing countries such as Indonesia the issues of transparency and human rights have been given more attention in recent years. Among the issues being addressed by families in an emerging civil society are the problems faced by the young generation related to globalization such

as permissive behavior, teenage pregnancy, substance abuse and HIV/AIDS. (1,2) As part of the Safe Motherhood project in Indonesia funded by the World Bank in recent years is adolescent reproductive health programs that focuses on Information, Education and Communication (IEC) 15

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in reproductive health, reproductive health services and counseling. (3) Pilots have specially been implemented in 10 districts dispersed in central and east Java. (4) In Jakarta as one of the largest metropolitan city in Indonesia has also developed similar program on adolescent reproductive health in several of its health centers. (5,6) Adolescents according to the World Health Organization are those in the population aged 10– 19 years. (1,7) While youths are those aged 15-24 years and those aged 10 – 24 years are known as young people. Many of these people are still going to school so that effective IEC programs on reproductive health at the school should focus on developing curriculum, media availability and training of counselors. The latter could be through the peer education approach where peer educators and motivators are recruited from potential adolescent health leaders and advocators in the student population. The objective of this study was to assess stakeholder perception on adolescent reproductive health clinics in Indonesia. METHOD An adolescent reproductive health clinic has been established in 1999 at Pasar Minggu district health center in south Jakarta. There are 108 primary schools, 20 junior high schools, 15 senior high schools and 3 colleges under its jurisdiction. The health center is located in one of its 7 subdistricts (Kebagusan sub-district). There are 9,678 households, total population 38,858 persons and area of 249.80 hectare. A series of stakeholder specific focus group discussions was held in a randomly selected subdistrict Pejaten Barat and its stakeholders were taken from the community related to a senior high school in its vicinity between July and August 2001. These stakeholders were adolescents (n=9), parents (n=6), community leaders (n=8) and health providers (n=7) divided respectively into small groups of 6–9 persons each. Criteria for inclusion in the respective focus group discussions were: 1) For adolescent informants were those selected from high school students actively involved in 16

Stakeholder perception

student body activities (OSIS) For parents were those with adolescent children. 3) For community leaders were those involved with community youth activities. 4) For health providers were paramedics directly involved with the clinic. Each group was requested to provide their comments on several themes related to the existence of an adolescent reproductive health (ARH) clinic in their community. The themes that were asked to the stakeholders were: 1) Existence of ARH clinic 2) Ever visited ARH clinic 3) Information on reproductive health (RH) 4) Knowledge on ARH clinic programs 5) Interest in ARH clinic 6) Obstacles in visiting ARH clinic 7) Importance of ARH clinic 8) Important ARH issues 9) Role of health provider in ARH clinic 10) ARH consultation preference 11) Factors influencing ARH quality 12) Interest in being ARH peer educator 13) Interest in ARH peer education 14) Type of ARH promotion preferred. Themes 12 and 13 were specifically directed to adolescents. These themes were listed in a Theme discussion guide prepared before the focus group discussion. Before the discussion the study team informed the informants on the aim of the focus group discussion and requested their approval in participating in the focus group discussion. Before the focus group discussion informants were requested to fill out a demographic data form. 2)

RESULTS Demographic profile of stakeholders Age of adolescents was below 20 years. Most adolescents were female. Adolescents had intermediate education. All students were unemployed or did not work during their spare time. Most adolescents were Javanese and Indigenous. However, overall they were quite heterogeneous (refer to Table 1). All adolescents were Muslims.

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Table 1. Demographic profile of stakeholders in respective focus group discussion, West Pejaten South Jakarta July - August 2001 Variable

Adolescent n (%)

Parent n (%)

Age (year) 15-34 35-54 >55

9 (100) -

2 (40) 3 (50) 1 (10)

3 (35) 4 (50) 1 (15)

2 (30) 5 (70) -

Gender Male Female

2 (30) 7 (70)

2 (40) 4 (60)

2 (30) 6 (70)

2 (30) 5 (70)

Education Employed Unemployed

9 (100)

3 (50) 3 (50)

8 (100) -

1 (15) 6 (85)

Ethnicity Indigenous Java Sunda Sumatera Other

2 (20) 5 (60) 1 (10) 1 (10)

1 (15) 4 (70) 1 (15) -

7 (85) 1(15) -

4 (60) 3 (40) -

Religion Islam Catholic Christian

9(100) -

6 (100) -

8 (100) - 1(15) -

5 (70)

Most of the parents were 35 years and above. Most parents were female. Most parents had intermediate education. An equal proportion of parents were employed and unemployed. Informants who were unemployed meant that they did not have a fixed income or take home pay obviously the majority were housewives. Most parents were Javanese and Indigenous. Most parents were Muslims. Most of the community leaders were 35 years and above. Most community leaders were female. Most community leaders had intermediate education. All community leaders were employed. Most community leaders were Javanese. Most community leaders were Muslims. Most of the health providers were 35 years and above. Most health providers were female. Most health provider had intermediate education. Most

Community leader n (%)

Health provider n (%)

1 (15)

health providers admitted to be unemployed. This is mostly due to their honorary status, which they perceived as not holding a permanent government job with its retirement benefits. Most health provider was Javanese and Sundanese. This is a reflection of the most dominant ethnic group in the western part of Java Island. Most health providers were Muslims. However, some health providers were Christians. This showed the affirmative action of the national government in its policy related to employee recruitment that reflected an Indonesian nationality outlook of diversity based on various religion and or ethnicity. Stakeholder perception on ARH clinics There were 14 Themes discussed in each focus group. The results of the focus group discussion were as follows (refer to Tables 2 and 3): 17

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Stakeholder perception

Table 2. Perception of stakeholders in focus group discussion on adolescent reproductive health clinic, West Pejaten South Jakarta July – August 2001 (Themes 1-7) Theme

Adolescent n (%)

Parent n (%)

Existence of ARH clinic Knows Doesn’t know Doesn’t care

9 (100) -

5 (80) 1 (20)

5 (60) 3 (40) -

7 (100) -

Ever visited ARH clinic Yes No Don’t care

9 (100) -

6 (100) -

8 (100) -

7 (100) -

Information on reproductive health Friend/ parent Clinic Mass media Don’t know Others

3 (30) 2 (20) 2 (20) 1 (15) 1 (15)

2 (30) 1 (20) 2 (30) 1 (20) -

2 (20) 2 (20) 3 (50) 1 (10) -

7 (100) -

Knowledge on ARH clinic program Knows Doesn’t know

9 (100)

6 (100)

5 (60) 3 (40)

7 (100) -

Interest in ARH clinic Interested Don’t know

8 (90) 1 (10)

6 (100) -

8 (100) -

7 (100) -

Obstacles in visiting ARH clinic Privacy No money Ashamed Too far

8 (90) 1 (10)

2 (30) 1 (20) 3 (50) -

5 (60) 3 (40)

4 (60) 3 (40)

Importance of ARH clinic Yes

9 (100)

6 (100)

8 (100)

7 (100)

ARH clinic existence Hundred percent of adolescent and 80% of parent did not know that the clinic existed in their area, while 60% of community leader knew about the clinic. At present, it seemed that the ARH clinic was not proactive in recruiting its prospective clients/users. Community leaders even though their intentions were good could only inform no more than 20% of parents and there seemed to be a 18

Community leader Health provider n (%) n (%)

communication gap between parents and adolescents. Ever visited the ARH clinic All informants except health providers had not yet visited the ARH clinic because they did not know where it was located in their vicinity. In this case the ARH clinic could distribute flyers to inform the public on the ARH clinic.

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Table 3. Perception of stakeholders in focus group discussion on adolescent reproductive health clinic, West Pejaten South Jakarta July – August 2001 (Themes 8-14) Theme

Adolescent n (%)

Parent n (%)

Community leader n (%)

Health provider n (%)

Important ARH issues Healthy relations Teenage pregnancy Substance abuse

8 (90) 1 (10)

3 (50) 2 (30) 1 (20)

4 (50) 1 (20) 3 (30)

2 (30) 4 (55) 1 (15)

Role of health provider in ARH clinic Yes No Don’t know

1 (10) 7 (80) 1 (10)

1 (20) 3 (50) 2 (30)

2 (25) 5 (60) 1 (15)

2 (30) 5 (70) -

ARH consultation preference One on one With parent With friend Hot-line

6 (70) 2 (20) 1 (10) -

3 (50) 1 (20) 2 (30) -

4 (50) 3 (30) 1 (20)

5 (70) -

Factors influencing ARH quality Social economic status Environment Family support Friends

2 (20) 2 (20) 5 (60) -

1 (20) 2 (30) 3 (50) -

3 (30) 3 (30) 1 (20) 1 (20)

4 (55) 3 (45) -

Interest in being ARH peer educator Yes No Don’t know

7 (60) 1 (20) 1 (20)

5 (90) 1 (10)

6 (75) 2 (25)

7 (100) -

Interest in ARH peer education Time consuming Volunteering No use Low knowledge

3 (30) 1 (10) 5 (60)

1 (20) 1 (20) 4 (60)

1 (10) 7 (90)

2 (30) 1 (10) 3 (60)

Type of ARH promotion Home visit Group Personal

1 (10) 8 (90) -

3 (50) 3 (50) -

8 (100) -

6 (85) 1 (15) -

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Reproductive Health (RH) information The main RH information sources for adolescents were peers and parents (30% respectively), while for parents it was friends/ other parents (30% respectively), and for community leaders it was the mass media (40%). Knowledge on ARH clinic program Hundred percent of adolescents and parent did not know what the programs of the ARH clinic were. However, community leaders knew more about the programs of the ARH clinic (60%). It seemed that at this stage, the ARH clinic had only been able to inform community leaders of its existence. This logically was a good initial step for ARH program development in this community. Interest in ARH clinic All of parent and community leader (100% respectively) showed interest in the ARH clinic, while slightly less of adolescents (90%) were interested in visiting the clinic. Obstacles in visiting ARH clinic Ninety percent of adolescents were ashamed to visit the ARH clinic, unless clinic surroundings were confidential. While 50% of parents said that the ARH clinic was located far from their home, 30% considered it as an invasion of their privacy and 20% of parents could not afford to visit the clinic. Sixty percent of community leaders were ashamed and 40% of informants said that it was situated far from their home. Surprisingly, 60% of health providers also felt ashamed whenever they as parents had to visit the ARH clinic and said it was situated far from their home (40%). It is assumed that the ARH clinic was not strategically located for all stakeholders to access. Besides all stakeholders considered that talking about sexual matters was still a taboo in this community and created a psychological handicap of being ashamed. Importance of ARH clinic All informants regarded the ARH clinic as important provided that ARH promotion and programs be implemented well and could contribute eventually to overall community welfare. 20

Stakeholder perception

Important ARH issues Ninety percent of adolescents considered healthy relations as an important ARH issue. While parents considered healthy relations (50%), teenage pregnancy (30%) and substance abuse (20%) as important ARH issues. Community leaders considered healthy relations (50%) and substance abuse (30%) as important ARH issues. Health providers considered teenage pregnancy (55%) and healthy relations (30%) as important ARH issues. Overall healthy relations seemed to be the core concern of all stakeholders. All of the stakeholders were also concerned about the issue of substance abuse and in certain cases its resultant teenage pregnancy. Role of health providers in ARH clinic Most adolescents (80%) said that the role of health provider was important for the daily activity of the ARH clinic. While parents, community leaders and health provider, 50%, 60% and 70% respectively, had similar response on health providers. However, there were quite a substantial number of parents (30%) who were unsure of the importance of health provider role. ARH consultation preference Adolescent (70%), parents (50%), community leader (50%) and health provider (70%) all preferred one on one consultation with a counselor as the main type of consultation. This reflected the community reluctance to discuss matters in public related to sexual behavior and promiscuity. These matters seemed to be a personal affair at least to informants in these focus groups. ARH quality factors Most adolescent (60%) and parents (60%) considered family support as an important factor influencing quality of ARH services, while community leader considered social economics and conducive environment (30% respectively) as positively influencing quality of ARH services. Health provider considered conducive environment (55%) and family support (50%) as positively influencing quality of services. Overall family support seemed to be the dominant factor influencing quality of ARH services.

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ARH peer educator Adolescent (60%), parents (90%), community leader (75%) and health provider (100%) were interested in participating as peer educators or in peer education. Interestingly, there were more parents compared to adolescents who were interested in becoming peer educators mostly for other parents especially for those having problems with their adolescent children. ARH peer education Interest in becoming peer educator or being involved in peer education was low because adolescent (60%), parents (60%), community leader (90%) and health provider (60%) felt their knowledge on adolescent reproductive health was still low. Interestingly, there were more community leader, a potential source and key target for reproductive health advocacy, who felt that they had still inadequate knowledge regarding issues of young people. Thus there is a need for more training on ARH for peer educators especially parents/ adults. ARH promotion preferred Adolescent (90%), parents (50%), community leader (100%) and health provider (85%) preferred ARH group promotion compared to home visits and personal communication. In other fields of public health focus groups had been promoted to better understand community problems and encouraging community solutions towards community empowerment and social development sustainability. In our case, parents seemed reluctant to discuss their adolescents’ problems with other parents at home but rather preferred group discussion. DISCUSSION Stakeholders were mostly female, Javanese and Muslim. Most of the stakeholders did not know that an ARH clinic was available in their community. Even though most of the community leaders knew about its existence. Major source of RH information of stakeholders was from other peers. Most of the stakeholders were interested in the ARH programs. Most of the stakeholders felt ashamed to discuss

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sexual matters in the community. All of the stakeholders considered healthy relations as the main ARH concern. Most of the stakeholders considered the role of health provider as important for ARH program dissemination. Most of the stakeholders preferred one-on-one type of ARH consultation. Family support was considered by all of the stakeholders as a major factor influencing quality of ARH services. Most of the stakeholders were interested in becoming peer educators. Surprisingly, a majority of parents were interested in becoming peer educators for other parents. Most of the stakeholders in particular parents were interested in peer education. Most of the stakeholders especially parents were interested in ARH group discussions. CONCLUSION In this case study we recommend that the ARH clinic be more proactive in communicating their ARH service to the community. This could be through dissemination of ARH flyers in the community. ARH advocacy is essential for program success. In this case community leader awareness is a good initial step, however, more advocacy should be directed to adolescents and parents in particular programs directed to bridge the communication gap between younger and older generation. In our case there is potential to develop peer educator recruitment and peer education groups for parents. In the community this program could be done through family clinics in urban and family groups in rural areas facilitated by a RH cadre specifically trained in family resiliency group dynamics. ACKNOWLEDGEMENT The author would like to thank the interns of the community health program in Trisakti University Jakarta for their assistance in conducting the field study. Reference 1.

Azrul Azwar. Kesehatan reproduksi remaja di Indonesia. (Adolescent reproductive health in

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Indonesia) Kongres Nasional IX Epidemiologi. Jakarta: Jaringan Epidemiologi Nasional; 2000. Arifin A, Suwandono A, Arifin F. Pengembangan pelayanan kesehatan reproduksi remaja di Puskesmas. (Development of adolescent reproductive health services at health center) Kongres Nasional IX Epidemiologi. Jakarta: Jaringan Epidemiologi Nasional; 2000. Medical Research Unit. Need assessment for adolescent health services in provinces of Central and East Java. Bandung: School of Medicine, Padjajaran University; 2000. Population & human resources division. Project appraisal document for a safe motherhood project: A partnership and family approach in Indonesia. Washington DC: World Bank; 1997. Pratomo H, Sidi IPS, Ambril AF, Handayani S.

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6.

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Peningkatan peran Puskesmas dalam mengembangkan pelayanan kesehatan reproduksi remaja: riset operasional di Puskesmas kecamatan Pasar Minggu Jakarta Selatan. (Development of a model of adolescents reproductive health services (ARHS) through Puskesmas (Public Health Center) in a sub-urban area of Jakarta, Indonesia) Kongres Nasional IX Epidemiologi. Jakarta: Jaringan Epidemiologi Nasional; 2000. Zarfiel Tafal Pengalaman pelaksanaan program remaja. (Experience in implementing adolescent program) Kongres Nasional IX Epidemiologi. Jakarta: Jaringan Epidemiologi Nasional; 2000. Departemen Kesehatan RI. Pola pembinaan kesehatan remaja dan pembinaan kesehatan keluarga. Jakarta: Departemen Kesehatan RI; 1996.