CHAPTER ONE
BACKGROUND AND METHODOLOGY
1. Background
Lesotho has an estimated population of 1.8 million people with an annual growth rate of
1.5%. The adolescent (10 – 19 years) population is large in most of the developing countries;
Lesotho is not an exception in this regard as her adolescent population is estimated at
21.8% of the entire population. The adolescent population is negatively affected by several
health problems such as substance abuse, teenage pregnancy, and rapid rise of HIV
prevalence. Unfortunately, if these health hazards affect adolescents it means that the
future society at large will be affected. The substance abuse normally has negative impact
on the general health of the adolescents themselves and their families. Several studies
show that substance abuse among adolescents in Lesotho is high and has negative impact
on their life in general (Ministry of Gender and Youth, Sports and Recreation (undated, the
Bureau of Statistics and UNFPA, 2002). Teenage pregnancy is also rising in Lesotho despite
efforts made by the Ministry of Health and Social Welfare and collaborating partners in
educating the adolescents about human reproduction as well availability of birth control
facilities (Kimane, Ntimo-Makara and Lebuso, 2008). The current trends show that in 2009
teenage pregnancy increased from 25% to 41%, while a rapid rise of HIV prevalence from
3% at the age of 15 – 19 to 20% at the age 20 -22 (The Kingdom of Lesotho, 2011). In 2008
Kimane et al notes that the HIV pandemic is worse among people who are within the age of
15 -49. The authors argue that the problem is worsened by social taboo where parents and
conservative schools do not discuss issues of human reproduction and sexuality with
teenagers. In addition to lack of information SIDA (2006) observed that HIV/AIDS in SubSaharan Africa emerged against a backdrop of extreme poverty, hunger, conflict and
inadequate infrastructure. These factors combined have exacerbated the spread of the
disease among young people as poverty has destroyed their social ambitions as well as
aspirations. UNAIDS (2006) recorded that adult HIV prevalence in Lesotho has remained
relatively stable in recent years but at high levels, with almost one person in four infected.
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The UNAIDS report further raised a host of challenges that Lesotho would need to
overcome in order to control the epidemic. It further noted that casual sex was common
among adolescents, yet the use of condom was infrequent. A significant proportion of the
adolescent had misconceptions about HIV/AIDS and some did not know how to prevent HIV
infection.
Statement of the Problem
In order to address the health problems facing the adolescents the Ministry of Health and Social
Welfare wants to improve the access and use of health services by adolescents. It intends to
develop the National Standards for Adolescent Health Services which will serve as a guide to all
stakeholders providing health services to adolescents in the country at large. This study will
provide information to inform the development of the standards as to the current situation of
service provision and use. It will identify gaps and priority areas on issues that affect
adolescents’ health services and needs. It may also serve as baseline information which could
subsequently be used to monitor the implementation of the standards.
Main Objective
The main goal of the study is to develop a comprehensive understanding of health services and
general practices in various health facilities in relation to addressing adolescents. The strengths
and weaknesses of these health services will be identified and critically analysed. The common
understanding of the practices will inform the process of developing the national adolescent
health standards.
Key Research Questions
What are the existing policies relevant to health services delivery to adolescents in Lesotho?
To what extent are the health services currently utilized by adolescents?
What specific group(s) within adolescents utilize the health services and for which health
conditions?
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What is the role of adolescents’ in the provision of health services?
What are the general weaknesses of the health service delivery in relation to adolescents’ in
Lesotho?
What are the strengths/good practices associated with health service delivery to adolescents in
Lesotho?
What can be done to improve the quality of health service delivery for adolescents’ in Lesotho?
What specific health services delivery should be provided to adolescents in Lesotho?
Rationale for the Review
The Ministry of Health and Social Welfare in collaboration with various partners has been
engaged for a long time in improving adolescents’ health problems. Among many strategies it
has adopted is the provision of health information through adolescents’ health services. It does
this through the provision of information, advice; counselling and clinical services aimed at
reducing health problems and health hazardous behaviours. It also encourages diagnosis,
detection, management of health problems; behaviours; and referral to other health and social
service providers where necessary.
The study on how these health facilities serve adolescents would serve as a critical source for
improving policy, services as well development of appropriate and relevant health standards for
adolescents in Lesotho. It will also assist the Ministry of Health and Social Welfare to identify
existing gaps, misinformation and inappropriate perceptions.
The health problem issues facing adolescents at the local villages are many and some of them
are related to limited health service delivery whereas others are exclusively cultural. For
example, regarding the latter the World Health Organization (2003) noted that
Not surprisingly, a key factor that influences adolescents’ health care-seeking behaviour
is whether or not the act of seeking health care could get them into trouble with their
parents or guardians. If, as in many cultures, social norms strongly forbid premarital sex,
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unmarried adolescents are likely to be wary about seeking care even if they have a
painful genital ulcer or a possible unwanted pregnancy. They are likely to deal with the
problem themselves, or with the help of friends or siblings whom they can trust to keep
their secrets. To ensure that that no one around them comes to learn about their
problem, they tend to turn to service delivery points such as pharmacies and clinics at a
safe distance from their homes, as well as to service providers who are keen as they are
to maintain secrecy (p.3).
The data collected through this study will help the Ministry of Health and Social Welfare to
sensitise the community to change attitudes that may discourage adolescents from utilising the
adolescents’ health services. The baseline data will also identify areas that need to be improved
in order deliver appropriate and relevant health services to adolescents.
Chapter 2
Methodology
The situational analysis was done in two approaches namely desk review and the empirical
research conducted with relevant participants. The first approach began with the collection of
documents that were related to the general health and service delivery for the adolescents in
Lesotho. Relevant documents that were available on the internet were searched downloaded
and printed as hard copies for reading and analysis. The hard copies were collected from the
various institutions in the country.
The documents that dealt with policy issues that affected adolescents were also collected, read,
analysed and summarised in order to develop the general understanding of policy issues that
addressed the adolescents’ health and efforts made by the country to reverse their situation.
The second approach of the study (empirical study) included interviews and focus group
discussions with some key informants of the study. The approaches were intended to
supplement each and provide reliable and authentic information regarding the situation of
adolescents’ health situation in Lesotho. The first approach (document review) reinforced the
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latter (empirical study) as it identified gaps in the document review and informed the latter in
terms of critical issues that were raised within the interviews and relevant focus group
discussions.
Population for the Empirical Study
Current health service delivery in Lesotho are organized into 18 health services areas which
include the Lesotho flying doctor service for remote and hard to reach areas. The main
government partner in health service delivery is the Christian Health Association of Lesotho
which provides services to more than forty percent of the population and the remaining sixty
percent is addressed by the government institutions. There are 20 hospitals of which 2 are
owned and purely operated by the private companies and not financed through government.
Within the identified health service areas the following critical informants were identified,
interviewed or participated in focus group discussions: adolescents, parents, village health
workers, service providers, facility managers and support staff. In addition policy makers at
central level were interviewed within the Ministry of Health and Social Welfare, Ministry of
Education, Ministry of Gender, Youth, Sports and Recreation.
The Scope/Area of Study Coverage
The following health services areas were purposively selected to represent the following critical
dimensions of Lesotho health services: facility ownership (government or religious
denominations), geographical location, urban or rural and district. In Berea, Leribe, Qachasnek,
and Mafeteng the Ministry of Health and Social Welfare had already established adolescents’
health corners so in addition to the main hospital there were branches that exclusively
addressed health delivery services for the adolescents.

Berea (two health facilities)

Botha-Bothe (two health facilities)

Leribe (two health facilities
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
Mafeteng two health facilities)

Maseru (four health facilities)

Qachasnek (two health facilities)
Sampling Procedure
Random sampling procedures are normally preferred for scientific and statistically robust
analysis (Leedy, 2000). However, in this case the above purposively selected health service
areas served as units of selection for one health service provider, one health facility manager
and one support Staff member. Parents, adolescents and village health workers were identified
in the catchment areas of each facility (i.e. the villages that were within the reach of the health
facility).
Data Collection Procedure
The instruments for data collection were adopted and modified from the international
instruments developed by World Health Organization. The following specific instruments were
localised; facility manager, service provider, adolescent, support staff, village health worker,
focus group discussion for adolescents. The adopted instruments were discussed, reviewed and
modified together with the Ministry of Health and Social Welfare and her local international
partners namely; UNICEF, WHO, UNFPA and BAYLOR. The instruments were further shared with
the internationally based team of WHO experts who made valuable inputs for improving the
instruments. The first draft of the interview guide for policy makers was made by one of WHO
international expert. The instruments for adolescents, parents and village health workers were
translated into the local language (Sesotho). The translated versions were shared with the
Ministry of Health and Social Welfare and her collaborating partners for modification and
approval.
Six research assistants (youth) were identified for this study. Three of them had just completed
a Bsc degree programme, three others were still at various institutions of higher learning in
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Lesotho and all of them had had an experience in conducting interviews as research assistants.
They were trained for one day to understand the interview guides as well as the focus group
discussion questions. The training component covered interview techniques, probing skills and
how to run focus group discussions. The training was conducted by the consultant in
collaboration with the Ministry of Health and Social Welfare and her partners namely UNFPA,
WHO, UNICEF and BAYLOR.
The field test of the instruments trial was conducted for one day in one of the health facility
providers in Maseru. During the field trial issues of ambiguity and confusions within the
instruments were identified and corrected. In addition to six research assistants there were
three female nurses who accompanied research assistants in conducting field work. In addition
to supervision of the field work the three nurses conducted the focus group discussions with
parents as it was not appropriate for adolescents to conduct focus groups with parents. The
health facility managers, health service providers and support staff were interviewed at the
health facility. In other words there was one provider, one facility manager and one
representative of the support staff at each health facility. Prior arrangements about the teams
coming to the facility were made by the officer responsible for adolescents’ health and services
at the central level of the Ministry of Health and Social Welfare and the arrangement helped
indeed as the teams were expected in various centres.
The target number of adolescents to interview in each catchment was ten adolescents.
However, in those cases where sufficient adolescents were not available at village level team
leaders decided to interview them at the health facility where they were available. In some
cases they were available in large number at the village level, in this situation they were
selected within the village cluster of Lesotho, where interviewers entered the first household
identified adolescent and if one was available the next household was skipped and entered the
third household. Where this procedure worked it gave the study a fair representation of the
adolescents within the village. In addition to individual interviews a group of 5 to 10 boys and
girls adolescents were grouped at (khotla) a chief’s place for focus group discussions. The
discussions at the village level were held in the open but it was ensured that only participants
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were within the location. During the focus group discussion one research assistant facilitated
discussions while the other took notes and recorded the general consensus of the discussion on
provided paper. Parental consent was obtained for the interviews of adolescents and the focus
groups. The rationale for the study was explained and the seeking of permission to participate
were done verbally and parents agreed and supported the idea of soliciting adolescents’ views
about health service delivery for the adolescents.
The nurse that accompanied research assistants had focus group discussions with 5 to 10
parents at the village level. The village leaders had already been informed that people from the
Ministry of Education and Social Welfare would come to the village and discuss some health
issues with his/her subjects. Therefore, there were more than 10 people at the chief’s place
waiting for Ministry of Health and Social Welfare, it was explained that the study needed only 5
to 10 participants and people simply complied. The discussion was also held at the chief’s place
in the open but again like with adolescents it was only participants who were allowed to be at
the place of focus group discussions.
Three were vehicles were hired and used for this study and three teams were formed where
each team was assigned 2 districts. Each team was made up of two research assistants
accompanied by one experienced nurse in issues of adolescents. The consultant accompanied a
team that went to Mafeteng and Maseru districts.
All teams had an introduction letter from the Ministry of Health and Social Welfare which
explained that the study was authorised by the Ministry of Health and Social Welfare. The
respondents were assured of confidentiality and it was clearly indicated that they were free to
participate in the study.
Data Analysis
Data collected were in two forms namely simple descriptive of the scenarios as stated by the
various responses from the questions. In this case the analysis simple reported information as
sated by various respondents. The general observation made about the state of the art in
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centres that provide adolescents’ health services. The issues of policies that may inhibit or limit
adolescents’ health services are reported. The qualitative analysis of data looked at themes that
had emerged from the discussion and what they could imply in terms of policy and improving
adolescent health services. Factors of commonality or trends were extracted, synthesized,
integrated and reported. The non open ended questions were captured into the computer for
calculating frequencies and descriptive statistics.
CHAPTER 3
PRESENTATION OF DESK REVIEW RESULTS
Introduction
The review is intended to establish the situation of adolescent health and services as well as
existing policies on issues that affect adolescents. The review is divided into three sections
namely; brief background about adolescent population in Lesotho, the thematic adolescents’
health problems in Lesotho, health services provided to adolescents and national policies
designed to address the adolescent health issues. The reviewed documents were mainly local
and most of them were obtained from the Ministry Health and Social Welfare, Ministry of
Education and Training and health partners of the Ministry of Health and Social Welfare.
Adolescent Formal Education in Lesotho
Education is the most powerful tool for human development in terms of psychological, social,
physical as well as economic development of adolescents. However, in Lesotho there are
adolescents who fail to progress with their educational career for various reasons. Among them
the following stand out prominently: high retention in Lesotho primary schools contributes
significantly towards adolescents dropping out of the formal schools; traditional practices that
are not harmonised with the formal school curriculum attracts many adolescents to drop-out of
school and attend such practices; the country has introduced free primary education but due
high unemployment most parents cannot afford school fees for secondary schools hence many
adolescents drop-out of the formal school (Lefoka, Nyabanyaba and Motlomelo 2012, Ministry
of Education and Training 2005). Access to tertiary education is also limited due to poor success
rates at higher school level (Examination Council of Lesotho, 2012). Lesotho Government, 2010
noted that all institutions of learning are characterised by high wastage as many adolescents
drop-out of the school systems before they finish their programmes. The situation still links
very well with the observation that was made by the Ministry of Education and Training 1992
which stated that:
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High repetition and dropouts rates in both primary and secondary schools characterize
the education system of Lesotho. For every 1000 pupils who start school, less than 50
percent of them complete the full primary cycle. At secondary level for every 1000
students who start Form A only 71 students are able to pass Cambridge Overseas School
Certificate (COSC). Many of them drop out in between the forms (P.25).
This scenario is bound to have a direct influence on the health of these young people. For
example, they usually find themselves facing the harsh challenges of life without any
preparation at all. As a result they are vulnerable to early marriage, sexual abuse, drug abuse
and a magnitude of other health problems (Ministry of Gender and Youth, Sports and
Recreation undated).
Adolescent Unemployment
Youth unemployment refers to share of the labour force ages 15-24 without work but available
for seeking employment. Unemployment among adolescent is high and it is getting worse
rather than improving. United Nations Statistics Division (2011) pointed out that in 1997 almost
59% of female youth were not employed and in the same period the general unemployment of
youth was 47%. The point being raised by bringing into the forefront unemployment of youth is
to sure how vulnerable to poor health issues adolescents are in Lesotho. Furthermore, the
United Nations Statistics Division points out that 40% of the Lesotho population lives below the
poverty and this is inclusive of the adolescent population. A study conducted by Motlomelo and
Sebatane (1999) noted that some of the reasons adolescents were engaged in health hazardous
issues were related to unemployment. For example, adolescents themselves reported that they
were engaged in alcohol drinking and smoking marijuana as a result of stress and frustration
resulting from boredom and lack of hope for the future. A high percentage reported that they
indulged in these practices because that was the only form relaxation and recreation available
to them in the rural areas. The combination of unemployment and lack of recreation facilities
create huge health problems for adolescents. The author further observed that job
opportunities are dwindling even for graduate students as many of them have not yet obtained
employment even after graduating from the university. This situation has a negative impact on
mental health, nutrition and many other health related issues. The views raised in this rather
old study were also raised by the government of Lesotho, 2006 where it was pointed out that
due to lack of employment opportunities adolescent were indulging in various drugs such as
alcohol and marijuana.
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Adolescent Pregnancy
Sexual activity among adolescents’ starts too early in Lesotho the Bureau of Statistics and
United Nations Population Fund (2003) noted that a significant portion of the adolescent
started the first sexual intercourse as early as 10 years. The Government of Lesotho, 2006
reported that sexual intercourse starts as early as the age of 12 for males and 14 for females
and increases to nearly 50% by age 17. The Bureau of Statistics and United Nation Population
Fund (2003) gave some dynamics of how this behaviour occurs. It is noted that in most cases
young girls had their first sexual intercourse with partners that were by far older than they
were and more experienced in sexual activities. They noted that these young girls were at a
high risk being infected with sexually transmitted diseases, especially HIV/AIDS which is
pandemic in Lesotho and the rest of Sub-Saharan Africa. It is also scaring to note that sexual
intercourse among adolescents takes place without formal relationship as the study reported
that that some adolescents reported that their first sexual intercourse was motivated by desire
to get money and goods. A study conducted by Motlomelo and Sebatane (1999) showed that a
large portion of adolescent who reported that the first sexual intercourse; were cheated into
sexual intercourse, followed by those who reported that they were coerced and those who
stated that they were sympathetic to their sex partners who were desperate for sex. The
Bureau of Statistics and United Nation Population Fund, 2003 also reported that
intergenerational sex is promoted by the false believe that having sexual intercourse with a
virgin would provide a cure for HIV/AIDS. These unfortunate believe and misbehaviour only
spread HIV/AIDS and destroy the future of the adolescents.
It is also alarming to note that this early sexual behaviour occurs without the use of
contraceptive as the Bureau of Statistics and Population Fund (2003) noted that:
Despite the high prevalence rates of HIV/AIDS in Lesotho, only one in ten males (10.4%)
and one in fourteen females (7%) used a contraceptive or protective sexual device the
first time they had sexual intercourse. Nationally, 91.6% of respondents did not use any
contraceptive or protective sexual device or method when they had sex for the first
time. Males and females living in urban areas were about twice as likely as their rural
counterparts to use a contraceptive or protective sexual device during their first sexual
activity, although even in urban areas, 82% of males and 87% of females did not use any
protection when they had sex for the first time (p.34).
The reasons for not using contraceptives are linked to lack of access and also not knowing
about contraceptives (Bureau of Statistics and United Nation Population Fund, 2003) and
Government of Lesotho, 2006).
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Teenage pregnancy traumatise the young mother and the family at large as in most cases they
are expelled from the formal school and in many cases they are not given a second chance to
pursue their educational career (Lefoka, Nyabanyaba and Motlomelo, 2008, Government of
Lesotho, 2006). Furthermore, some traditional families normally arrange a forced marriage if a
young girl gets pregnant. This situation is summed up by Kimane, Matora Ntimo-Makara and
Lebuso (2008) as follows:
…early marriages involving young people of teenage ages are still common especially in
the rural areas. It is observed that in a number of cases these are arranged by parents
particularly in cases where pregnancy has already occurred. The point emphasized by
some respondents is that these cases can be considered to be “forced marriages” since
the consent of the young people concerned is never solicited nor are they ever given the
opportunity to make choices for themselves whether they want or not want to get
married (p.14).
The author noted that in Lesotho primary schools and secondary schools; there were no
counselling facilities for the students. Therefore students who are traumatised by early
pregnancy are not given any professional counselling. The schools add to their trauma by
expelling them from schools. It is true that the government policy says all children must have
access to basic education. But the fact of the matter is that the government has no strategies to
enforce the policy as most schools in Lesotho belong to religious church denominations which
are very strong on issues morality. In almost all religious church denominations in Lesotho sex
outside marriage is sanctioned so teenagers who fall pregnant before marriage either go into
unplanned marriage or they are expelled from school (Lefoka, Nyabanyaba and Motlomelo
2012). It is worth emphasising that this happens despite the government policy that no
adolescent shall be denied access to education as a result of falling pregnant.
Adolescent Contraception and Safer Sex
The Government of Lesotho, 2003 noted that even though awareness of contraception and
safer sex is high among adolescents in Lesotho. Unfortunately, this awareness does correspond
with practice on the ground as teenage pregnancy is very high as well as sexually transmitted
diseases. There are several factors that could contribute to this unwanted state of the art. The
Government of Lesotho, 2003 made a strong assertion that this situation could be attributed to
limited access to health-friendly services. The report further noted that adolescents and other
youth tend to feel alienated by the crowded outpatient clinics and the lack of empathy
demonstrated by medical personnel.
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In Lesotho, despite high levels of awareness about HIV/AIDS and increased condom
distribution, condom use and acceptance remains low. Government of Lesotho 2011 reported
that only 37.5% of women and 50.5% of men who had two or more sexual partners reported
using a condom during the last sexual intercourse. This is also a very important revelation for a
country that rates third in the world on issues of HIV/AIDS pandemic. The Bureau of Statistics
and United Nations Population Fund, 2003 reported that majority of people who used
contraceptives did so in order to delay or avoid pregnancy rather than to avoid contracting
sexually transmitted diseases. The study showed that few respondents saw both male and
female condoms as strong weapons that could be used against HIV/AIDS in Lesotho or at their
community level.
The other critical factor that inhibits the use of contraceptives among adolescents is rooted in
the fact that there is very little communication between spouses and sexual partners about
family planning and other related issues. A study by the Bureau of Statistics and United Nations
Population Fund, 2003 noted that between 50% and 70% of the respondents never discussed
issues of safe sex with their spouses. This could be attributed to the fact that in rural areas of
Lesotho women are generally much younger than their husbands so they may not be able to
discuss openly issues of sexuality as young women may not be free with their senior husbands
or partners (kimane, Matora Ntimo-Makara and Lebuso, 2008). The Government of Lesotho,
2006 noted that although there was a high level of awareness about contraception majority of
Basotho had not changed significantly in their sexual practices of multiple and concurrent
unprotected sexual relationships.
It was also noted that very few adolescents understood a female’s menstrual cycle, when they
were most at risk of becoming pregnant and how that information could be used to avoid
pregnancy. The study showed that less than 10% of respondents including female did not know
when a woman in her menstrual cycle would stand a high chance of conception (The Bureau of
Statistics and United Nations Population Fund (2003).
HIV/AIDS Sexually Transmitted Disease
Lesotho is the third country in Southern Africa and the world with the highest burden of HIV
and AIDS and with an estimated adult prevalence of 23% among the 15-49 groups (Government
of Lesotho and UNAIDS, 2005, Kingdom of Lesotho, 2011). The orphan population of Lesotho is
estimated at about 117,000 in a population of 2.2 million. It is estimated that about 70
HIV/AIDS related deaths occur daily; the nation is facing unprecedented national disaster
(Government of Lesotho and World Health Organization, undated). Kingdom of Lesotho, 2011
noted that approximately 21,000 new adult infections and 4000 new infections among children
occurred annually.
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The situation of HIV/AIDS in Lesotho is summarised by the Bureau of Statistics and United
Nations Population Fund, 2003 as follows:
HIV/AIDS has become not only a health problem in Lesotho but also an economic and
development problem. HIV/AIDS is affecting the young, professional, highly educated
and most productive sector of the economy at rates that have been projected to lead to
a decline in economic growth, life expectancy, and population growth and an increase to
poverty and food insecurity. High levels of HIV/AIDS have not only led to an increase in
mortality at all age groups from infancy to the middle age groups but has also led to the
disorganization of families and households, the creation of a pool of orphans and
vulnerable children and an increased pressure on health resources (P.75).
A closer look at the Sentinel Surveillance data indicates that the prevalence among adolescents
aged 15-19 years was 8.9% in 2007 and 9.9% in 2009. Further the reports noted an increase in
prevalence among the group 20-24 years from 24.4% in 2007 to 24.8% in 2009. There was an
increase in prevalence among the age group 15-24 from 18.7 in 2007 and 19.7 in 2009. There
was also an increase among the age group 15-24 from 18.7% in 2007 and 19.7% in 2009. There
is a wrong notation that HIV/AIDS infection is high in the urban area is compared to rural areas.
The fact is that in Lesotho the line of demarcation between rural and urban area is very small as
most of the people have their roots in urban areas. The very same people who seem to reside
in urban areas are also residents in the rural areas. However, it is an undeniable fact that
adolescents who are out of school but reside in urban areas are at high risk of infection due to
low income that needs to be supplemented by risk behaviour such infidelity (my emphasis).
Mortality and Morbidity During Pregnancy and Child Birth
Phafoli, Aswegen and Alberts, 2007 noted there was a delay in deciding to seek antenatal care
among pregnant teenagers in Lesotho. This subsequently leads to delay in reaching treatment
and in receiving adequate treatment. The authors argue that early antenatal care attendance
plays a major role in detecting and correcting complications of pregnancy and forms a good
basis for appropriate management during delivery and after giving birth. Despite the fact that
antenatal care is provided at different levels, the country still has a high maternal mortality
rate, estimated at 762 per 100 000 live births, and an infant mortality rate of 72 per 1 000 live
births (Phafoli, Aswegen and Alberts, 2007, UNICEF and WHO and Lesotho Demographic Health
Survey, 2004).
The other problem that compounds mortality and morbidity during pregnancy and child birth is
the long term shortage of health personnel in Lesotho. The desperate situation is summarised
by Phafoli, et.al, 2007 as follows:
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This shortage of Health care personnel and the impact of HIV/AIDS result in insufficient
focus on health promotion in reproductive, especially birth preparedness, and lack of
community participation and male involvement in reproductive health care issues. Early
sexual activities with consequent early pregnancy lead to high maternal and neonatal
morbidity and mortality (p.1).
In order to address these issues, the National Adolescent and Development Programme was
started in 1998 by the Ministry of Health and Social Welfare. This programme developed
adolescent’s health corners. Despite this noble innovation for adolescents, delay in antenatal
attendance is still prevalent in Lesotho. Out of 632 pregnant teenagers in 2003 who attended
the clinic at Queen II adolescent corner, the majority (43%) visited the antenatal clinic for the
first time during the third trimester and only 14.9% attended the first trimester. This late
antenatal clinic attendance provides little or no time for appropriate screening, management of
risk factors, if detected, and timely referral (Phafoli, et.al, 2007).
Factors that contributed towards delay in attending antenatal services were as follows: lack of
knowledge regarding the importance early attendance, denial of the pregnancy by the boy and
living the girl traumatised and not willing to share her agony with parents, the fact that sex
outside of marriage in Lesotho is still taboo and uncultured discourage adolescents to attend
health services (Phafoli, et.al, 2007).
Maternal mortality ratio is very high and has almost tripled over a period of 8 years. It has
increased from 282/100 000 live birth in 1996 to 419/100 000 live births in 2001 and 762/100
000 in 2004 (Lesotho Demographic Survey, 2004). The document further estimates the life time
risk of maternal at 1:32. It is true that this estimation is based on women not necessarily
adolescents but it is indeed an issue of concern as indicated that in Lesotho the issue of early
pregnancy is high.
Neonatal mortality increased from 44/1000 live births to 46/1000 live births while infant
mortality rate increased from 75/1000 to 91/1000 live birth over a five year period (Lesotho
Demographic Survey, 2004).
Traditional Practices
There are some traditional practices that have negative impact on adolescents’ health. These
practices are rooted in the cultural and societal norms. In Lesotho some pockets of forced
marriage still exists among adolescents. For example, it is common in rural areas for girls to be
forced into marriage through abduction (chobeliso). It is highly unlikely that someone that has
been forced into that type of a marriage can discuss issues of family planning, sexual education
and use of condoms with the forced spouse (Government of Lesotho, 2003). There is also a
15
general believe that a wife should be younger than her husband, while there is probably
nothing wrong with this practice; the fact remains that if age difference is wide a wife and a
husband do not talk easily about sexuality (Kimane, Matora Ntimo-Makara and Lebuso, 2008).
Practices such as lobola (bohali) tend to subject young newly married adolescents’ to the status
of a minor as there is a general feeling that she has been sold to the family of her husband
(Matsela and Motlomelo, 2000, Government of Lesotho, 2003). It is a practice that is deeply
rooted in Basotho culture and denies women an equal right to determine their fate and also
decision to practice safe sex within marriage. Traditional practices such as polygamy are a
threat to adolescents’ health because by customary law men are allowed to marry as many
wives as long as they can afford to provide them with necessary basic support such as feeding
clothing and shelter Matsela and Motlomelo, 2000, Government of Lesotho, 2003).
In Lesotho there is a common practice where male adolescents’ attend the traditional school
called lebollo. In this school young men are initiated into manhood through several traditional
ways, one of them being circumcision. The main problem with this practice is that it is carried
out by individuals that are not trained in human anatomy and modern medicine. Therefore
these young people risk being infected by various types of diseases. It is not clear how this
critical procedure is undertaken in an environment where scientific procedures are not
available (Matsela and Motlomelo, 2000). This is a serious concern as these traditional schools
are not prepared to share their activities with the modern medicine which could easily assist in
this special operation.
Nutrition
The nutritional status of the adolescent population in Lesotho could only be assessed and
observed within the context of the country as a whole. Since 2000 Lesotho has experienced
unprecedented levels of acute food insecurity. Only 30 percent of food needs are covered by
domestic crop production, the rest being supplemented by food aid and imports. HIV/AIDS,
food and nutrition insecurity are becoming increasingly entwined in a vicious cycle (Lesotho
Government, 2005).
Specifically the nutritional status of adolescents in Lesotho has not been directly explored; it is
therefore not easy to come up with accurate statistics on the issue. However, the nutritional
status of the female adolescents be inferred from the pregnant adolescents’ pre-natal and
ante-natal visits to health centres. Their medical records are able to indicate diseases related to
nutritional deficiency, for example, anaemia, malnutrition and general iodine deficiency are
commonly identified among these adolescents. Some of the nutrition problems affecting the
16
adolescent population are very complex and almost impossible to identify since they result
from childhood problems (Phafoli, et.al 2007).
Malnutrition may also be a serious problem in Lesotho due to high unemployment and
frequent droughts that have seriously affected the country. A related common problem is
ignorance about balanced diet, particularly in rural areas (Sechaba Consultants, 1998). There is
also an observation that, culturally, some people still discourage adolescents from eating food
that is rich in protein. This obviously has an impact on the nutritional needs of these people
(Morojele, 1994). The World Health Organization (1995) noted that there were serious cases of
anaemia in most of the African countries as a result of deficiency in their diet. This was
particularly evident in women that were under the age of 20, most of whom were identified
during pregnancy and after delivery. In Lesotho secondary schools cases of students who could
not perform well in schools as a result of malnutrition have been reported (Lefoka, Nyabanyaba
and Motlomelo, 2012).
A study conducted by Motlomelo and Sebatane, 1999 noted that the general awareness of
nutrition was high among adolescents, however, the study noted that nutritional awareness
without availability of the right food in the family did not solve the problem. Perhaps, in
addition to nutritional facts adolescents should be introduced to the necessary skills to produce
food where need arises. This observation consistent with what Lefoka, Nyabanyaba and
Motlomelo (2012) recommended to schools that rather than observe students who have not
eaten any food at home, schools could come up with programmes where students can learn
and also produce food. This observation was in line with the high rates of orphans in schools
and students who did not have parents to supervise their homework as a result of HIV/AIDS
pandemic.
Rape
Rape is defined as any sexual intercourse with another person without his or her concerned.
The issue of rape is a national concern because it is believed that it is generally on the rise (The
Bureau of Statistics and United Nation Population Fund, 2003). It is again very difficult to come
up with accurate statistics of rape as it is a sensitive and painful experience and many people
prefer not to disclose the experience, especially where it happened with people that are
related. For example, young girls are often raped by their step fathers who normally provide
them with basic needs of life (Lesotho time, June, 2012). Lesotho Time, June 2012) reports that
every day there is a case of sexual assault and most of the victims are adolescents or young
girls. The Bureau of statistics Crime Statistics Report; noted that cases of rape among young
girls are indeed on the rise. A study conducted by the Bureau of Statistics and United Nation
17
Population Fund, 2003 noted that indeed rape was common in Lesotho and significantly high
among 15 to 19 years.
In showing the difficult dynamics of rape United Nation Population Fund, 2003 noted:
Some instances of forced sexual intercourse may not be recognised as rape because the
definition of what constitute rape is often unclear to the rape survivors or their families.
It is often not clear if females can rape males or if a husband can legally said to have
raped his wife or a man his lover, especially if the two of them have previously been
having sexual intercourse. Because of the payment on marriage, of lobola or bride
wealth, in the form of several herds of cattle for women, there is tacit acceptance that a
husband can demand sex of his wife at any time and expect to receive it. It thus difficult
to accept that that a husband can be legally said to have raped his wife, even when he
forcibly sex with her against her wish (p.145).
The point being raised is that rape is common among adolescents but it not reported due to the
circumstances under which it occurs. There is again a common believe among some people
who are infected with HIV/AIDS virus that having sexual intercourse with a virgin that is not
infected will cure the disease. This misfortune encourages men to rape young girls and babies
to a certain extent (Bureau of Statistics and United Nations Population, 2003, Lesotho Planned
Parenthood, undated and Kimane, Matora Ntimo-Makara and Lebuso, 2008).
Abortion
The Ministry of Health and Social Welfare (2003) noted that the low use and sometimes in
accessible contraceptives among the adolescents contributes to high rates of unwanted
pregnancies which encourage abortions among adolescents. The report further stated that
some adolescents commit unsafe abortions when they realised that they were pregnant. These
adolescents use extremely dangerous methods to terminate unwanted pregnancies. The
Ministry of Health and Social Welfare (2003) noted that some use the following:
…drink mythylated sprit, medicinal herbs and other corrosive preparations. Others use
sharp instruments which may result in perforation of the uterus, severe bleeding,
infections and psychological trauma that may lead to sterility and severe bleeding which
result in death. This increases the maternal mortality rate as well (p.71).
The point being raised above is that unsafe abortion is a problem among adolescents and
unwanted pregnancy is the main factor contributing towards abortion among the adolescents.
18
The Ministry of Health and Social Welfare cited by the Government of Lesotho 2006 showed
that in 1997 16.8% of all hospital deaths for female over the age of 14 years were due to
abortion complications. The Facility-based surveys indicated that 13% of all abortion cases seen
were among adolescents. However, some authors argue that there were no reliable figures to
indicate the magnitude of abortion in Lesotho since it is illegal. Therefore, most of the
information on the magnitude of this problem comes from the hospital based records. It is
worth noting these records are indeed a tip of the iceberg since some adolescents still live
beyond the reach of modern health services. My emphasis
Morojele (1991) reviewed court cases of abortion and came up with diversified reasons why
women resorted to unsafe abortion. The most common reason was fear of being expelled from
school, which certainly has serious implications for the future of the adolescent concerned, as
well as the children to be born. Secondly, some women stated that they resorted to abortion
due to limited financial resources in the family. Others were still breast feeding when
pregnancy occurred. The third was rape, which was never disclosed for fear that the victim
might not be believed by the family and community at large. Unsafe abortion does occur
among adolescent in Lesotho, although its magnitude may not necessarily be measured by
statistics. The Bureau of statistics (2003) also noted that the rate of abortions among young
people were on the rise.
Substance Abuse
Tobacco smoking is common among adolescents in Lesotho. There is well documented
evidence that tobacco has serious health problems for smokers as well as those residing in the
same house. Bureau of Statistics and United Nations Population Fund, 2003 noted that nearly
one in five adolescents' males (18.3) and 3.4 percent of female adolescents had smoked
cigarettes and tobacco. In Lesotho both traditional and modern alcoholic drinks are available to
any one who has money to buy it regardless of the age (my emphasis). Government of Lesotho
2006 reported that the percentage of children aged less than 10 years using cigarettes was
12.5%, while 5.7% was using alcohol, marijuana was used by 6.7% and glue was used by 11.2%.
The percentage use by those who were 10-14 year age group was as follows: Cigarettes 46.6%,
alcohol 46.9%, dagga 31.7%, glue 64.3%. The percentage use in the 15-19 year age group was as
follows: cigarettes 39.6%; alcohol 47%; dagga 60.7%; glue 21.3%. Substance abuse is a serious
problem among Lesotho adolescents and it needs special attention.
19
Violence
Violence among adolescents in Lesotho is common and it comes in different forms. Lesotho
Times June, 2012 noted that sex predators target minors and inflict sexual assault. The Bureau
of statistics Lesotho Statistical Reports Crime Statistics indicated that almost every day there
were reported cases adolescents that had been physically assaulted. In Maseru the capital city
of Lesotho, there are centres that deal with children in crisis, most of these children were
rejected or abused by their families. All these centres were full to their capacity and most of
them were looking for relatives to reunite with these young people. Livestock is rampant in
Lesotho and the victims in most cases were young boys that lived with animals in harsh remote
areas of Lesotho. The crime report statistics (2005) noted that these young people were used
by stock theft criminals to steal animals on their behalf. When they are caught in most cases
they were terrible assaulted before they faced justice. The crime report statistics report
statistics (2005) noted that there were several cases of young boys that had been killed on
suspicion that they had committed certain crimes.
It has been noted earlier in the review that teenage marriage was common and supported by
law. Therefore it was apparent that adolescents experienced spouse abuse in Lesotho as it is
very common. Matsela and Motlomelo (2000) noted that some teenage fathers tend to proof
their manhood by abusing their wives and children. The authors noted that in rural areas where
young boys and girls marry without resources and depend on the boy’s family, this unfortunate
practice is often encouraged by the mothers in law.
Lefoka, Nyabanyaba and Motlomelo (2012) observed that there was a lot of corporal
punishment in Lesotho schools even though it was not allowed by law. This excessive form of
punishment forced students to drop out of the school. Some teachers and parents felt that
these form of violence was justified as children these days were stubborn. Unfortunately this
view is not supported by any scientific theory.
Mental Problems
There is no accurate statistics on mental problems among adolescents in Lesotho, because
there is only one health hospital that deals with people that have problems of that nature.
20
Chapter 4
The Situation of Adolescents Services
Adolescent Friendly Health Services were established by the Ministry of Health and Social
Welfare to address health issues that focused mainly on youth. Adolescent Health Corners were
formed in 1999 in Leribe, Maseru and Mafeteng. The Ministry of Health and Social Welfare
expanded these important services to 23 health facilities through out the country. A study was
mandated in 2008 to assess the effectiveness of these facilities in relation to mandate. The
methodologies followed were review of documents, focus group discussions and interviews
with key stakeholders in the programme.
The study discovered that many of the adolescent health corners did not function as only 17
were functional and fully operating. Unfortunately, even few that were operating would not be
qualified as adolescent friendly. The study pointed out that 53% was fair and 47% was not
acceptable and therefore not rendering the expected services. It is need less to underscore that
it is very critical for the Ministry of Health and Social Welfare to upgrade the adolescent health
corners as they play a major role in promoting the general welfare of this critical sector of the
population. The study noted that operating hours were not suitable for the adolescents as they
were operating from 8:00 am to 4:00 pm from Monday to Friday. It is evident that these
operating hours were not convenient for adolescents as they were attending school and not
able to get services within the scheduled hours. Generally these adolescents’ health corners
were located at an appropriate site within the community. However, it was observed that space
was not sufficient and it acted as a hindrance towards provision of effective and appropriate
service. For example, issues of confidentiality were compromised and this discouraged
adolescents from participating or getting services from this important health corners.
It was observed that generally these important corners lacked critical issues that would attract
adolescents. For example, posters that had information that would attract young people or any
information that would be exciting to the young people.
Trained staff to service adolescent health corners is very critical and fundamental to the success
of the programme. However, it was observed that generally the adolescents’ health corners
were managed by individuals that were poorly trained in issues of adolescent health. The study
further noted there was a recent development towards engaging a male manager to manager
the adolescent health corners and it was hoped that this new endeavour would improve the
state of the art.
Generally in Lesotho the nursing staff is made up of female so the adolescents’ health corners
are generally managed by female. Young boys raised concern that they would rather be served
21
by the male nurse. It was also observed that some service providers were unconformable in
providing services to clients that were under the age 15 as they were probably not well trained
in dealing with young people. The other limitation that emerged was that service providers
were well grounded in providing counselling services which are very critical for adolescent
health corners.
Adolescent health corners were limited in their training approaches as they did not offer
informal education on sexuality, reproductive health and safe sex which is very critical during
this HIV/AIDS period. The main services that were provided were related to issues of pregnant
teenagers and this generally discouraged young boys from participating in activities related
adolescent health corners.
The study concludes that even though there are policies and guidelines regarding provision of
health services to this particular sector of the population. Most of them were not well
disseminated to this particular group and members of the community at large. In conclusion
the study observed that adolescent health corners were fairly friendly though there was a need
for improvement so that they could attract adolescents. It was observed that it will be critical
that adolescents themselves to take part in identifying critical learning needs to be provided in
their curriculum.
Adolescent health corners are a very important innovation in Lesotho because they address the
needs of the young people in their own environment. It was the author’s opinion that if
adolescent health corners could be strengthened, indeed they could serve as powerful change
agents, particularly for some of traditional habits that impact negatively on adolescent health
issues.
22
Chapter 5
Review of Policy Documents Regarding Adolescent Health
Lesotho has policies that are aimed at improving the general health of adolescents. It is
apparent that some of these policies; even though they are not exclusively directed at
adolescents do have a bearing on improving the health status of adolescents. The policies
are reviewed in order to establish the intention of Lesotho in collaboration with her
partners in addressing adolescents’ health needs.
The National HIV and AIDS Testing and Counselling Policy for the Kingdom of Lesotho in
collaboration with World Health Organization (undated ) is an example of a policy that
includes adolescents within the larger social sector. The specific goals of the policy are as
follows: to create a conducive climate for HIV testing and counselling such that many people
will be encouraged to know their status; create conditions for behaviour change in all areas of
sexual and reproductive health; to ensure that behaviour change and attitudes about HIV and
AIDS are based on correct and scientific information; to ensure that adequate attention is paid
to vulnerable groups such as women, youth and children; to create an environment of
collaboration among various stakeholders in the provision of appropriate health services to the
nation at large (Adolescents included), finally the provision of linkages and access to relevant
post-test services.
The policy further addresses critical issues such that HIV testing shall not be compulsory except
under conditions which the document does not specify. Furthermore the policy states that HIV
testing shall not be a precondition for employment, admission to educational institutions,
provision of a medical service, enjoyment of human rights and civil liberties, including the right
to enter into marriage and normal family life. This policy even though is not directly focussing
on adolescents is a giant step in protecting adolescents, especially on issues of employment and
access to education.
The policy emphasises the importance pre-testing counselling, confidentiality and non
discrimination of clients. It is also stated in the policy that post-test counselling shall be
provided when delivering HIV test results. The policy states that vulnerable and special groups
shall be supported to access HIV testing and counselling without any form of discrimination.
The policy emphasises quality service for the clients as a result HIV testing and counselling will
be monitored to ensure quality. The policy further stressed that only those HIV test kits
registered in Lesotho shall be used for testing in the country. This approach is very critical for
ensuring quality services as the kits would have been reviewed and evaluated before
registration in Lesotho.
23
The policy gives powers to Ministry of Health and Social Welfare to ensure good practices by
ensuring that all institutions involved in HIV testing operate in accordance with set national
standards. This practice would ensure that personnel and equipment involve in testing is of the
correct standard.
The National Reproductive Health Policy (Government of Lesotho, 2009) is a critical policy as
well, since it pronounced itself on the following critical health issues: recognition of the
fundamental human rights to health provision of sexual and reproductive health care services
to all Basotho without any form of discrimination; alignment of the policy with relevant policies
and legal instruments to ensure a rather inclusive approach to sexual and reproductive health
care services; universal access to sexual reproductive health care services that are acceptable
and affordable to all Basotho.
The policy is clear about the intention to increase access to sexual and reproductive health care
services to all community to 80%. The policy further outlines the strategies it would follow in
order to achieve this noble and huge target. The policy intends to increase utilisation of sexual
and reproductive health care services at all levels of care by 80%. Among strategies to be
employed is to remove financial barriers, user friendly health services and appropriate
approach to clients by health services providers. The other critical strategy in the context of
Lesotho is to take on board traditional cultural sectors as well as religious groups to ensure that
all individuals have access to stated sexual and reproductive health goals.
The policy intends to increase nationwide the number of facilities providing comprehensive
quality sexual and reproductive health services at all levels of health care. The policy proposed
to increase the then current budget for sexual and reproductive health services by 15%. The
policy intended to ensure that the essential package of sexual and reproductive health services
shall be made available to all levels of the health system in Lesotho. The package among others
should have included the following: safe motherhood, family planning, post-abortion care,
sexually transmitted infection, gender based violence, HIV and AIDS, male involvement in issues
that affect sexual reproductive health. The policy indicated that the strategic plan would be
developed to ensure that the stated policies are implemented.
National Adolescent Health Policy (Government of Lesotho, 2006)
The policy began by outlining the state of the art regarding the health problems facing
adolescents in Lesotho. The policy covers teenage pregnancy, contraceptive prevalence,
STIs/HIV and AIDS prevalence rates, abortion rates, sexual abuse and violence, substance
abuse, gender issues, disability, mental issues, injuries, nutritional problems. The policy showed
that there is no reliable statistics on non-communicable diseases among adolescents in
24
Lesotho. The policy indicated the political commitment in Lesotho to reverse the state of the art
regarding adolescents’ situation in Lesotho. In summary the policy showed diverse health
problems of the adolescents. It further showed the commitment and direction that needs to be
taken in order to improve the general health of the adolescents in Lesotho. The policy set
specific targets and strategies for reversing the adolescent health situation.
The national adolescent health policy calls for commitment and goodwill of all stakeholders.
The policy calls for a coherent and coordinated actions as well as continuous monitoring and
evaluation in order to achieve the main goal of improving the general health of the adolescents
in the country. The policy has good intentions but it is limited on suggesting where the funds
would come from for the general improvement of health of the adolescents. However, it is
encouraging to note that the policy recognises that the success in improving the general health
of adolescents cannot be achieved by government alone, hence a strong suggestion that all
partners and other line ministries should work in collaboration under the leadership of the
Ministry of Health and Social Welfare.
School Health Policy of Lesotho (Ministry of Education and Training, 2005). The policy does
not exclusively address adolescents as it addresses all young people within the school
environment. The policy aims at creating an enabling environment for the implementation of a
wide range of health services within the school going population. The policy sees the school
environment as the right place to legitimise the advocacy and social awareness activities for the
protection of children rights through education and information. The school is further seen as a
centre where various key health players including the family, civil society and development
partners could join hands in promoting and supporting the general health of young people
adolescents included.
The policy stated that good health is a fundamental right and equity must be applied in school
health. The policy further suggests that school health must adhere and be guided by principles
of social justice and non-discrimination of the young people within the school environment. The
policy reiterates that partnerships, networking and alliances are critical in ensuring that health
delivery services are provided within the school environment. The other critical aspect of the
policy is its pronouncement that the issues of health services shall be integrated in school
curriculum; cultural habits that are known to be health hazardous shall not be promoted within
the school environment. Health information and services according to the needs of the
intended clients shall be a pre-requisite for implementation and health services in school shall
be based on professional standards of practice.
The policy is very critical as it outlines the health standards that should maintained within the
school, for example, it raises issues of safe learning climate, no discrimination, no sexual
25
harassment, no substance abuse, and provision of sanitation, right to all forms of health
information and access to HIV testing and counselling at all required levels.
The school health policy states that no person shall be denied access to reproductive health
information; young people below the age consent should get access to services if consent has
been granted. In order to prevent early sex, unwanted pregnancy, STIs and HIV the policy
recommends that the formal schools should assist in delivering information and services. The
policy further suggests that pregnancy and motherhood shall not be used to exclude girls from
attending school. Cultural practices that promote poor health and social welfare are
discouraged by the school policy. For example, forced marriages shall be discouraged and not
allowed by law.
The policy intends to socialize and encourage school boards to appreciate and allow
distribution of services such as condoms. Health corners, peer counselling and other youth
clubs shall be encouraged to improve the general health of the adolescents. The policy intends
to improve rights of the child, physical education, recreation, food and nutrition services,
psychological guidance and counselling services and the general welfare of all school
community.
National Social Welfare Policy (Government of Lesotho, 2002). The policy does not exclusively
address adolescents only, however, it has a section that deals with issues that have a bearing
on adolescents’ health. The specific issues relating to adolescents are the intention of the policy
to improve education and employment of adolescents. The policy also touches on critical
efforts to reduce HIV and AIDS infection among adolescents. Furthermore, the policy indicates
the intention to improve access to friendly reproductive health service information. The policy
makes a commitment to support adolescents through appropriate counselling and necessary
support on issues related to their diverse social problems. The policy makes a commitment to
assist adolescents in issues of early sex, pregnancy, general health problems and how they
could cope with the dynamics of the modern world. The policy acknowledges that adolescents
are prone to substance abuse as well as crime; therefore it makes a commitment to help
adolescents to overcome or reverse these problems. In conclusion the policy notes that issues
of unemployment and lack of food security must be addressed in order to improve the general
welfare of the adolescents as well as the entire population.
National Family Planning Guidelines (Ministry of Health and Social Welfare, 2012). The
document is not a policy, but it has some good intentions on improving the general health of
adolescents. The section on adolescent notes that the needs of this special group depends on
their particular situation and may present not only the need for contraception but also advice in
relation to physical changes, sex, management of relationships, family, and the general
26
problems associated with growing up. The complex nature of this special group is that some are
married therefore sexually active; others are not married but sexually active and sometimes
have children, while others are not sexually active. The challenge therefore, is to strike the
balance in providing appropriate services according to the specific needs.
The document notes that there shall be no discrimination in providing services to this special
group. However, the emphasis is on provision of services with care and thorough understanding
of the client and his/her needs. The document outlines strategies that should be taken into
consideration before providing services to adolescents. Among many; the following are critical
in the context of Lesotho: counsel in private areas to ensure confidentiality, use of appropriate
language, avoid judgement statements, address fears, and misinformation about sex, sexually
transmitted infections and contraceptive.
The document clearly states that all adolescents married or not married have a right to
contraceptive and information about service delivery as well as information about general good
health. The document concludes by indicating that adolescents should have information about
all forms of contraceptives. The good aspect of the document is articulation of the strategies to
address the needs of the adolescents.
Education Sector Strategic Plan 2005-2015 (Ministry of Education and Training, 2005). The
plan raises some critical issues that have a bearing on adolescents’ health. The plan commits
itself to ensuring that there is gender equality within the school system, secondly the school
environment should be safe for all children and teachers and the schools should respond to
challenges raised by HIV and AIDS.
The document also makes a commitment that schools should serve as focal points for good
health among all school participants. The plan touches on problems related to sexual and
reproductive health and makes a commitment to working with various stake-holders to inform
school community about good health practices.
It makes a commitment to undertake the following: establish structures for effective
coordination of the multi-sectoral national AIDS programme; mobilise adequate resources for
national AIDS Programme; increase information; education and communication programmes;
involvement of youth in all programmes that aimed at reducing new infections; reduce high
rates of sexually transmitted diseases and intensification surveillance and testing of HIV/AIDS.
The document acknowledges that in order to improve adolescent health in general schools
must work in collaboration with various stake-holders in addressing issues that affect the
general health of adolescents.
27
The National HIV and AIDS Strategic Plan (Government of Lesotho, 2006-2011). The plan
outlines the national response to the pandemic. The plan shows that HIV prevalence is
significantly high from the age of 15-49. The plan shows the cultural issues that could easily
spread the virus. Among many factors the following are raised: inequality and lack powerful
strategies to empower women, substance abuse that normally leads into risky sexual practices,
intergenerational relationships which normally lead to cohesive or cheating young girls into
sexual relationships. The plan also indicates that insufficient information about HIV and AIDS
could contribute significantly towards worsening the situation regarding the infection.
The plan is addressing the situation through aggressive provision of information and education.
It goes further to provide services such as condoms to reduce the rate of sexually transmitted
diseases. The plan also has strategies to encourage people to know their status. The strategies
for counselling prior to testing and after testing are in place. The plan suggests that individuals
working with adolescents on issues of HIV and AIDS should be well trained to do their work
effectively. The services needed for prevention as well as those needed by people that are
already infected should be made available. The HIV and AIDS pandemic has created many
orphans than ever before in the history of Lesotho. The plan suggests that there should be an
increase of services to orphans and their vulnerable groups such as sex workers.
National Action Plan on Women, Girls and HIV and AIDS 2007-2010 (Ministry of Gender,
Youth, Sports and Recreation, 2006). The plan is based on premise that women and girls in
Lesotho are not allowed by cultural practices to fully participate in decisions that affect their
life. The plan argues that this situation makes women and girls vulnerable to HIV and AIDS
infection as well as various types of sexually transmitted infection. The plan intends to address
prevention of HIV and AIDS among women and girls, the general education of girl child at all
forms of education, gender based violence and also ensuring that women and girls have access
to HIV and AIDS treatment and appropriate care without any form of discrimination.
The plan raises cultural practices such as young girls having sexual relationship with men that
are older than they are for financial reasons make these girls vulnerable sexually transmitted
diseases. Practices such abduction, which often followed by rape increases chances of girls
being infected with sexually transmitted disease including HIV and AIDS. The plan is to sensitise
society at large about these issues so that laws that prohibit these practices could be easily
understood and applied. The plan further notes that violence against girls in school is promoted
by poor understanding of gender sensitive issues by both teachers and students, therefore it is
critical to ensure that education is provided within the school. The plan notes that young girls
who do not seek reproductive health services do not come for voluntary counselling and testing
28
and the challenge is to make sure that they also have access to health service in one form or
another.
The National Youth Policy (Ministry of Gender and Youth, Sports and Recreation, undated).
The policy touches on critical issues such as stimulating environmental awareness amongst the
youth and their responsibilities towards sustainable environment and reduction of poverty,
ensuring that the type of education and training provided is compatible with and responsive to
the needs of the youth so that they could use their education to improve their general health
standards.
The policy spells out that it would sensitise youth about national problems such as HIV and AIDS
and negative effects of population growth. It goes further to indicate that it would use
information and education to change behaviour that might be harmful to the adolescents and
young people. The policy pledges intensification of the efforts and possible methods to combat
drug and substance abuse. The policy plans to encourage open communications channels
between parents, schools and the youth. The street adolescents will be encouraged to link with
their appropriate family structures.
29
CHAPTER SIX
PRESENTATION OF EMPIRICAL STUDY RESULTS
Introduction
The chapter presents the results of the empirical study. It begins with data from the facility
managers and service providers, support staff and followed by the presentation of adolescents’
responses and various focus groups analysis. The information from the facility managers and
service providers is presented jointly as their instruments were similar and focussing on very
closely related themes.
Characteristics of Facility Managers and Service Providers
Fifteen health facility managers were interviewed and they were fairly distributed according to
health facilities as follows: Scott hospital 1; Machabeng hospital 3; Litsoeneng health centre 1;
Berea hospital 1; Mafeteng hospital 2; BAYLOR 2; Leribe youth centre 1; Motebang hospital 1;
Butha Buthe hospital 1; St. Peters health clinic 1 and Lesotho Planned Parenthood Association
1. They were also fairly distributed according to the selected districts as follows: Botha Bothe 2;
Leribe 2; Berea 1; Maseru 2; Mafeteng 3; and Qachasnek 5. Most of them (12) were in the
urban region, 3 were in the rural areas. In terms of gender they were distributed as follows:
male 4 and 11 female. The period they had taken working at the facility was diverse as it ranged
from 2 to 360 months.
Twelve health service providers were interviewed, they were distributed according to health
facilities as follows: Scott hospital 1; Machabeng hospital 2; Litsoeneng health centre 1; Berea
hospital 1; Berea health resource centre 1; BAYLOR 1; Leribe youth centre 1; Motebang hospital
1; St. Peters health centre 1 and Berea youth centre 2. In terms of districts their spread was as
follows: Botha Bothe 1; Leribe 2; Berea 2; Maseru 3; Mafeteng 1 and Qachasnek 3. Ten were
located in the urban area and two were in the rural place, eight were in the lowland, one
foothill and three were in the mountain region. Ten were female and two were male. The
length of time they had taken serving the health facility ranged from 3 months to 132, time was
so diverse that the mean would not make any sense as the standard deviation was huge. The
age range of the providers was 26 to 56 years.
Common Understanding of What is an Adolescent
In order to establish whether health care providers had a common understanding of what is an
adolescent, the study asked their opinion on what was their understanding of an adolescent.
The results showed diverse responses as the following definitions were raised: children below
30
20 years that is between 9 and 20; 14 to 18 years; 10 to 20 years; 10 to 19 years; 10 to 15 years;
12 to 25 years and 10 to 24 years; the transition from childhood to adulthood. This information
reveals that there is a need for clarification of what age is an adolescent so that health services
that are directed to adolescents should focus on the appropriate target audience. The results
show that those who are assigned to provide services to adolescents had confusion on who was
an adolescent and why. Adolescence is not determined by the body size of the youth but by the
age as defined in several international conventions.
Adolescent-friendly Health Services: Policies and Procedures are in Place that do not restrict
the provision of Health Services on any terms
On the whole both facility managers and service providers reported that there were no policies
or procedures at their facilities that might restrict the provision of health services to some
adolescents. One respondent said “we do not discriminate against any adolescent as our
obligation is to provide services to all; the only service we do not provide is abortion”. There
was one respondent who reported that if abortion was allowed by law it would be one of the
services they would provide at their facility as many adolescents end up doing the procedure
with unqualified and non professional institutions and this poses a threat to adolescents’
health.
When asked to describe the characteristics of some of the adolescents who may be less likely to
receive services, the facility managers and health service providers raised the following
common issues and themes: adolescents who requested abortion; mentally retarded
adolescents; physically challenged; drug addicts and sex workers.
Policies and Procedures are in Place that Ensure that Health Services are Either Free or
Affordable to Adolescents
On the whole (12) facility managers reported that adolescents were not charged for specific
health services at their facilities. However, there were three who reported that there were
specific health service charges. They reported that all consultations were paid for, anti natal
care costs M15 which was reported to cater for all care throughout the period. It was reported
by the three facility managers that issues related to contraceptives cost M7.50. One facility
manager reported that in his facility the following contraceptives cost as follows: pills M20.00
for the entire cycle, injection M15, EC M50.00.
Facility managers who did not charge any fees were supported by government and some donor
agencies, for example, BAYLOR reported that all health related services were free because they
were funded by the donor agency. One health facility manager reported that they did not have
any specific services for adolescents so they charged fees that they were charging to all clients
31
who came for services. It is therefore apparent that there are still financial barriers in other
health facilities that inhibit adolescents from utilizing health services.
The responses on whether fees for adolescents’ clients were different from the fees for adults,
the results were diversified as some facility managers said yes, and others said no, whereas
others reported that there were no fees charged at all. It was reported that adolescents who
did not have finance for health services were referred to social welfare and social welfare was
the main sponsor of the adolescents who needed services but cannot afford to pay for such
services. The respondents reported that even though in some of their facilities there were no
policies for concessions. However, they reported that sometimes they gave services to
adolescents even if they could not afford payment. One facility manager reported that in his
health facility they often made concessions for adolescents with disability, street adolescents,
and sex workers. It is indeed evident that as much as some facility managers made concessions
there were some adolescents who still did not access health services due to financial
limitations.
The Point of Health Services Delivery has Convenient Hours of Operation
The working hours for almost all health facilities were from 8:00 in the morning to 4:30 in the
afternoon from Monday to Friday. There were only two health facility managers that reported
working hours from 7:30 to 5:00 in the afternoon. It was generally reported that these hours
were not convenient for most of the adolescents as they were in school during these working
hours. The facilities that extended operation hours from 7:30 in the morning to 5:00 in the
afternoon did so in order to cater for the needs of the students. In conclusion it was apparent
that operation hours were not appropriate for adolescents who were in school. It was clear that
schools and health facility services should collaborate in ensuring that certain health services
were provided within school premises, particularly because the Ministry of Education and
Training has a policy on general improvement of the adolescents’ health and health services.
Some Health Services and Health-Related Commodities are provided to Adolescents in the
Community Members, Outreach Workers and Adolescents Themselves.
Health facilities in Lesotho provided health facilities to adolescents in the community. They
provided services in the form of visits to schools to provide health education on issues of
reproductive health; community outreach services; HIV and AIDS testing and counselling;
sexually transmitted infection treatment and general information about HIV and AIDS; family
planning, distribution of both male and female condoms; education about adolescents in
general. The two facilities that reported not to offer any community health services did so
32
because they did not have sufficient manpower to undertake the task but in principle they felt
that they needed to provide health services to the community.
On the issue of whether adolescents were involved in any these activities. Almost half (7) said
adolescents were involved and they were involved in the following areas: participate by
teaching concepts to others during the training; in HIV and AIDS; train peer educators to
provide general health information; they educate others about HIV and AIDS prevention; serve
as agents for behaviour change among other adolescents; distribute condoms and serve as
motivational catalysts for other adolescents to stand up and prevent early pregnancy, stop HIV
and AIDS infection as well as sexually transmitted infection.
Health Care Providers Treat all Adolescents Clients with Care and Respect regardless of Status
When asked if there were some groups of adolescents who they did not feel comfortable in
providing them with services. The following issues emerged: adolescents that were below the
age of 12 are not easy to provide with condoms and other family planning suppliers unless they
came with a parent or guardian; physically challenged and mentally challenged individuals were
also not easy to provide with reproductive health facilities because of their situation; drug
addicts were mentioned but the interviewers did not probe why it would be difficult to provide
them with health facilities. Finally gays and lesbians should not be provided with facilities as
their practices were not accepted and respected by the culture of Lesotho.
Community Members Understand the Benefits that Adolescents will Gain by Obtaining the
Health Services they Need, and Support their Provision
The community members supported the provision of health services for adolescents, but the
respondents were not in full agreement of support in relation to reproductive health. The
community members who supported the provision of health services encouraged their children
to come to the clinic for various health services. They also allowed their children to participate
in information sharing about health services and education related to the general improvement
of other adolescents and how they should work towards improving their life for a better future.
In addition to their work at the health facility, service providers also provided extension
education to adolescents in their various local communities. The services that were reported to
be offered were as follows: General health education, problems that were caused by unplanned
pregnancy, pregnancy diagnosis; school visits to talk about good health in general; the role that
adolescents could play in reducing HIV and AIDS pandemic.
33
Policies and Procedures are in Place that Guarantee Client Confidentiality
Facility managers and health care providers reported in almost one voice and said there were
policies or procedures in place that guaranteed the confidentiality of adolescent clients in their
facilities. When asked to mention what the policies said the following responses were common:
the oath of the nurse is that she/he shall not disclose information about client health problems
rather than for the purpose of assisting the client to get a better health; they had guidelines
that guarantee confidentiality regarding clients health issues; patients rights charter; it is the
facility policy that no member of staff shall disclose patient information without a reason and
permission of the authority; every patient has a right to confidentiality and privacy; posters
showing rights of clients; HIV and AIDS manual; declaration and dedication of confidentiality
were signed by all members of the staff; it is general code of conduct among all members of our
staff; reproductive health policy; clients rights policy and sexual reproductive rights.
The above responses showed that respondents did not exactly know what the policies said, but
rather mentioned the names of various policies and declaration charters related to
confidentiality. This showed that in order to improve confidentiality and confidence of clients in
health services providers and facility managers, there should be a serious effort to educate the
health personnel about the contents of various policies and declarations that they seem to
know by names only.
When asked if there were specific action/procedures to protect the confidentiality and how
they were applied the facility managers mentioned the following issues: reference was made to
confidential procedures all the time; consultative meetings were held with staff where an
appeal was always made to members of the staff to ensure confidentiality of the clients;
frequent reminders of the staff about how critical it was to keep clients health issues
confidential; all our staff were frequently exposed to in-service training and the emphasis was
on observing confidentiality about clients health issues; finally a serious effort was made to
ensure that clients were consulted on individual and private environment.
All service providers reported that there were circumstances where they would not observe the
policies of health facility confidentiality, for example, if an adolescent was pregnant one of the
critical issues would be to call a parent in order to council both. Secondly if an adolescent
needed a special service and in the judgement of the provider that adolescent needed parental
concession the confidential code would be violated.
34
The Point of Health Delivery ensures Privacy
Most of the facility managers (12) reported that there were guidelines in place to provide
privacy for adolescents clients and very few (3) reported that there were no guidelines. In order
to cross check if the guidelines were observed the providers were also asked if they were ever
interrupted while providing services to the clients and on the contrary, most of the providers
(9) reported that they were often interrupted while they provided services to the clients. This
implies that the points of delivery had some challenges regarding ensuring privacy. In general
health care providers (8) said it was not possible for other people to hear what conversation or
counselling sessions while in the consultation room with the adolescent clients. However, on
the other hand there were few voices (2) that claimed that privacy was limited as other people
could hear what was actually said in the consultation room.
In order to assess the extent to which consultation rooms could also serve as sources of
information for adolescents, the facility managers were asked if there were informational and
educational materials available for adolescents in the waiting room. It is of significance concern
that about three facility managers reported that they did not have consultation rooms and
adolescents’ clients were waiting for services outside. However, for the twelve who reported
that they had consultations rooms the following issues were available: educational posters;
pamphlets and demonstration models; family planning material; child growth; prevention of
breast cancer information; vaccine for children, booklets about human sexuality and negative
effects of human abortion.
Adolescents are Actively Involved in Designing, Assessing and Providing Health Services
Facility managers were asked if they gave adolescents opportunities to suggest/recommend
changes to make services more responsive to adolescent clients. Almost half (7) of the
respondents reported that they gave adolescents opportunities to suggest and recommend
how services could be improved to meet their needs.
The opportunities given to adolescents were as follows: talk to each other and council each
other about their general welfare; meetings with adolescents were held every month to discuss
issues that affected their general health; discuss issues about their future; discuss best health
practices and suggestion box where they could easily suggest areas of improvement.
Facility managers who did not give adolescents opportunities to suggest and recommend
changes reported that in principle they would like to do that but time did not allow them to do
so as they were extremely busy. There were also other voices that raised the issue of
insufficient staffing as a major factor contributing towards why adolescents were not involved
35
beyond being consulted as clients and a general believe that adolescents did not know much as
a result to consult them may be a waste of time.
When asked if in addition to being consulted as clients, adolescents were currently involved in
decision making about how health care services were delivered to adolescents, half of those
who responded to the question said yes and the half said no. Those facility managers, who said
yes, reported that adolescents were involved in the following activities: gave suggestions on
how best they could be served; encouraged other adolescents to test for HIV and AIDS so that
adolescents could know their status; they worked in collaboration with public health nurses to
discuss issues of adolescents’ health in their schools.
Facility managers who reported that they did not consult adolescents indicated that this was
due to lack of time as the facility was extremely under staffed. The emphasis was that they
would want to involve adolescents in decision making about how services were to be delivered.
The Point of Health Service Delivery Ensures Consultations Occur in a Short Waiting Time, and
Swift Referral
Almost all but one service providers reported that they knew procedures for making referrals
for adolescents. When asked to describe the procedures, the following issues were raised: write
recommendation letter stating the needs of the adolescent; write in the adolescent health book
what the client should be provided with; filling in of the referral forms and accompany the
client to the referral health facility. All respondents reported that adolescents’ clients were
provided with some form of assistance with the referral. When asked to describe the form of
assistance the following issues were raised: they are normally directed to where they should go
for referral services; accompanied the client to the referral place to ensure that they would
indeed go to the referral place and phone the doctor who would attend to the adolescent
client.
The Required Package of Health Care is Provided to Fulfil the Needs of All Adolescents Either
at the Point of Health Service Delivery or Through Referral Linkages
The majority of facility managers (nine), and all service providers (12) reported that adolescents
were offered information and counselling on reproductive health sexuality and safe sex, only
three facility managers offered testing and counselling services for HIV whereas 10 facility
providers offered the service. Three facility managers acknowledged that they offered STI/RTI
diagnosis and nine service providers reported that they offered the service, only two facility
managers reported offering pregnancy diagnosis and seven health facility providers reported
that they provided the service. The treatment for STIs/RTIs was offered by three facility
managers and nine service providers said they offered the service. One facility manager
36
reported that the treatment of STIs/RTIs treatment was referred to some other health facilities.
Care during pregnancy was offered by one facility manager, two facility managers reported that
they did not offer such a health service and one reported that adolescents were referred to
other health facilities, 10 facility providers reported that they offered the service and only two
reported referral. One facility manager indicated that the facility offered care during childbirth,
while two reported that they did not offer such a service whereas one reported that it referred
adolescents to other health facilities on the same issue, six service providers reported that they
offered the service whereas, three reported not providing such a service and two reported
referral. Two facility managers offered care after childbirth, one noted that it did not offer such
a facility and one reported referral of the adolescents, 7 service providers provided the service
and two reported referral. Two facility managers said they offered post abortion services, seven
service providers reported that they provided the service, one pointed out that referrals were
made and one said such a service was not provided. Information and counselling on
contraception, including emergency contraception was reported by three facility managers,
seven service providers claimed that they offered the service; two reported no such service and
the other two said they made referrals. Information and counselling about condoms was
reported by five facility managers as one of the services the health facility provided to
adolescents, all service providers reported that the service was provided. The care and support
for HIV positive adolescents was offered by four health facility centres and one reported that it
did not offer such a facility, all service providers reported that such a service was offered. Care
and support for adolescent clients who have been physically or sexually assaulted were offered
by two facility managers whereas one reported referral for such victims, six service providers
indicated that the service was offered two reported referrals and three said the service was not
offered. Four facility managers reported treatment for such victims was followed by regular
follow ups to maximise cure, one reported that the facility did not offer such a service. Seven
service providers reported that the service was not offered; two reported referral and two said
the service was not offered.
The general observation is that according to the facility managers the health service facilities
offer limited service to adolescents. But on the contrary service providers present a different
picture.
When asked if some services were not available, did their staff know how and where to refer
clients for these services. All facility managers reported that they knew their fellow workers
service providers eight said they knew what to do. When asked if their staff had a skill in
providing information and counselling on reproductive health, sexuality and care, all facility
managers reported yes, six service providers reported adequate knowledge and five said they
did not have adequate knowledge. Regarding testing and counselling services for HIV seven
37
facility managers reported that their staff members were knowledgeable to perform the tasks;
seven service providers said they had knowledge and one felt he/she did not have knowledge.
For STI/RTI diagnosis only five facility managers reported that members of their staff had the
knowledge and skill to perform such a task, six service providers had knowledge and one did
not have knowledge. On the issue of pregnancy diagnosis six facility managers reported that
their staff had knowledge and skills, seven service providers had knowledge; two said they did
not have knowledge.
Five facility managers reported that their staff had knowledge and skills necessary for the
treatment for STIs/RTIs, seven service providers had knowledge and only two reported that
they did not have knowledge. Care during pregnancy was reported by five facility managers as
one area where their staff members were knowledgeable; eight service providers felt they were
knowledgeable. Care during childbirth was also reported by five facility managers as an area
where staff is competent, eight service providers were knowledgeable. Regarding post abortion
services the scenario changed as only one facility manager reported that the staff of the health
facility had knowledge and skill to provide the service, six service providers had skill to provide
the service. Three facility managers reported that their staff had knowledge and skill to provide
information and counselling, on contraception, including emergency contraception, nine service
providers had knowledge. Four facility managers reported that their staff members were
knowledgeable about information and counselling on condoms while seven service providers
were knowledgeable about the above issues. Care and support for HIV positive adolescents
was reported by four facility managers as an area where members of the staff were
knowledgeable and seven service providers knew. Four facility managers and four service
providers reported that their staff had knowledge to provide care and support for adolescent
clients who have been physically or sexually assaulted and skills in following up adolescents’
clients who have been physically or sexually assaulted.
Health-Care Providers Use Evidence-Based Protocols and Guidelines to Provide Health
Services
Three facility managers were able to show information and counselling on reproductive health,
sexuality and safe sex and two service providers were able to show such information; three
facility managers and three service providers showed information on testing and counselling
services for HIV; three facility managers and six service providers showed information on
STI/RTI diagnosis; two facility managers and two service providers had information on
pregnancy diagnosis; non of the facility managers had any and one service provider had
information on treatment for STIs/RTIs; three facility managers and seven service providers had
information on care during pregnancy; non of the facility managers showed information on care
38
during childbirth while two facility providers showed such information; three facility managers
had information on care after childbirth and two service providers showed that information;
facility managers and service providers showed nothing on abortion; three facility managers
displayed information and counselling on contraception, including emergency contraception
and two service providers showed such information; three service managers showed
information and counselling on condoms only two service providers showed such information;
three service managers had information on care and support for HIV positive adolescents and
two providers had such information; four service managers showed some information on care
and support for adolescent clients who have been physically or sexually assaulted and two
service providers showed that information and both groups of adolescents showed no
information or protocols on treatment and follow up to adolescent clients who have been
physically or sexually assaulted.
The Point of Health Service Delivery has the Required Equipment, supplies, and Basic Services
Necessary to Deliver the Required Health Services
When asked if the health facility had a system for maintaining an inventory and recording the
amount of medicines and supplies in stock nearly all (13) reported that they had a system.
When asked if in the last six months, they had had shortage of medicines and supplies that
disrupted the provision of any health services offered only two services managers said yes. The
supplies that ran out were as follows: HIV test kit; oxygen; eye drops; and cloves.
When asked if in the last six months, there had been unavailability of equipment or nonfunctioning equipment that disrupted the provision of any health services offered, five facility
managers said yes they had experienced such problems. The equipments that disrupted the
services were as follows: blood pressure machine, HB meters, non-functioning equipment, CD4
count machine.
Health service providers when asked if they had all medicines and supplies they needed to
manage their patients’ needs, four reported that they did not have enough medication and five
reported that they had enough medication. Six service providers reported that in the last six
months they had experienced shortage of medicines supplies that disrupted the provision of
any health services offered. When asked to mention the medicines and supplies that were
missing the following were reported: ARVS for children and adults, depo-injection, nuristrate
injection microgynon, microlut, implants, cotrimoxazole 960 mg, HIV test kits and STIs
treatments.
When asked if they had all the equipment they needed to manage their patients, six service
providers said that they did not have sufficient equipment and four reported that they had such
39
equipment. In the last six months service providers unavailability of equipment and nonfunctioning equipment disrupted the provision of any health services as five service providers
reported that they were disrupted and five said were not disrupted. Service providers who
were disrupted were asked to list the equipment and the following were listed: Hb machine;
CD4 reagents; BP Cuff; thermometer; speculum; digital scale; Bp machine and computer
When asked if they had supervision for the services they provided to adolescents seven said yes
and two said there was no form of supervision. When asked to mention the type of supervision,
service providers referred to the ordinary daily routine of checking if one is at work rather than
evaluation and monitoring of the service. When they experienced complicated cases they often
refer the matter to their seniors.
Health-care Providers are Able to Dedicate Sufficient Time to Work Effectively with their
Adolescent Clients
The general feeling of the service providers was that they did not have sufficient time with
adolescents as only five reported that they had enough time. When asked if sometimes they
had to see the clients quickly because there were many clients waiting to be seen, five said yes,
and six reported that they did experience such a situation.
Capacity Needs of Adolescents’ Health Service Providers and Facility Managers
When asked if their college/university included adolescent’s health needs, seven health
providers said yes, and nine facility managers reported that their training included such needs.
When asked to mention the main issues that were addressed, the following issues were
mentioned: teenage pregnancy; sexually transmitted diseases among adolescents; community
health education; how HIV virus is transmitted and counselling adolescents that were infected;
reproductive health; family planning; biological changes that occurred during the adolescents
stage; antenatal care and post natal care; behaviour change among adolescents; adolescents’
psychology and behaviour; communicating with adolescents and motivating adolescents to
work hard towards building a better future for themselves.
Both groups reported that in-service training on issues of adolescents was very limited as only
two facility managers and three service providers reported to have attended an in-service
programme relevant to needs of the adolescents.
The few who reported to have attended in-service training on issues related to adolescents
reported that the training covered the following issues: the biological needs of adolescents;
psychological needs and functioning of adolescents; how to communicate with adolescents;
family planning and contraception.
40
Both groups expressed desire to participate in such training and such training should involve
the following issues: how to involve adolescents in taking care of their health; training on
adolescent health needs in general; guiding adolescents to make appropriate decisions so that
they could lead a better future in terms of health; how to communicate with adolescents; skill
in counselling adolescents; every necessary skill that affected adolescents health; current issues
on reproductive health and the rights of the adolescent in general.
Data from Support Staff
Characteristics of the support Staff
There were ten support staff members who were interviewed; they were fairly distributed
throughout the health facilities as follows: St. Joseph hospital 1, Scott hospital 1, Berea hospital
adolescent corner 1, Mafeteng hospital 1, Machabeng hospital 2, Baylor Qachasnek 1, St. Peters
1, Botha Bothe 1, and Motebang 0. They were also fairly distributed according to the selected
districts as follows: Botha bothe 2, Leribe 1, Berea 1, Maseru 3, Qachasnek 2 and Mafeteng 1.
The most represented region was lowlands with 6 participants, 2 from the foothill and 2 from
the mountains. Almost all participants were female with only 1 male. The age range for working
at the facility ranged from few months to years.
Almost all (8) staff members provided any type of health service to the community outside the
facility and only 2 did not provide such a service. When asked to mention what they did, the
following issues were raised: individual counselling with adolescent clients (8); general health
care of the adolescents (6); child care and development; health talks with adolescents and
motivating them to become responsible members of the community who care for themselves
and each other (1); visit schools frequently to talk about the general health of adolescents.
Nearly all (8) members of the staff said that adolescents were involved in providing any type of
health service to adolescent in the community. The forms of services were generally awareness
about HIV and AIDS as well as appealing to others in relation to moral values. This was done
through distribution of health information booklets, pamphlets as well as educational drama to
pass message to others.
When asked what they perceived as the major health needs of the adolescents in the
community the following issues were raised: change of behaviour regarding substance abuse,
prevention of HIV and AIDS, teenage pregnancy were mentioned by all respondents; general
information on health related issues was mentioned by 2 respondents; spots and recreation
facility was raised by 1 respondent.
41
The issue of substance abuse and teenage pregnancy is a problem that has emerged across all
sources of information and it needs to be seriously addressed as in many cases it is the main
cause of other problems that are affecting adolescents in Lesotho.
The training needs raised by support staff focused mainly on skills that would help them solve
what they perceived as major problems facing adolescents in the community. For example, all
of them reported that they needed training to address substance abuse, teenage pregnancy,
HIV and AIDS as well as skills necessary to mobilise adolescents in the communities to produce
food so that they could supplement what is available in their various homes. One respondent
felt that she was behind in terms of current information on issues that affected adolescents;
therefore it was raised as a training need.
When asked if there were any specific or additional health services that they would like to
provide to the adolescents only two respondents addressed the question. The issues of family
planning philosophy among adolescents is very critical, much as it was provided, the
respondent felt that much could be done as covers key elements that could help adolescents to
improve their general welfare. All support staff reported that there were cases of adolescents
that they had to refer to a health facility.
The issues that were referred were as follows: suspected teenage pregnancy, serious and any
form of illness that could not addressed. All support staff reported that adolescents were not
involved in providing any type of health service to adolescents in the community. It is indeed
critical that adolescents should be involved in the distribution of health services in their own
communities as this will give them a sense of responsibility and leadership which is very
important in helping adolescents to shape their future.
Data from Adolescents
Characteristics of Adolescents
There were one hundred and fourteen (114) adolescents interviewed for this study, they were
distributed as follows in terms of health facilities: Scott hospital 10; Litsoeneng health centre
12, Berea 8; Berea youth centre 7; mafeteng hospital 9; BAYLOR Qachasnek 2; Qachasnek
hospital 13; Motebang hospital 14; Botha Bothe 8; St. Peters 12; LPPA 1; St. Joseph 5; and
BAYLOR Tsepong 8. In terms of districts they were distributed as follows: Botha Bothe 20;
Leribe 14; Berea 15; Maseru 27; Mafeteng 23 and Qachasnek 15. There were 57 adolescents
located in the urban area and 45 in the rural while 12 cases did not report their location. 77
were located in the lowlands, 12 foothills and 15 were in the mountains and 10 cases were not
reported where they belonged. The adolescents interviewed were mainly female as there were
79 (71%) female and 33 (30) male. This is not a surprising finding as boys are not always at
42
home due to taking care of livestock if not in school. The age range of the adolescents who
participated in study was 12 to 20 with a mean of 16 and standard deviation of 2. This shows
that the individuals interviewed were generally within the defined age adolescence which is 10
to 19 years.
Most of the respondents were students as 62 (62%) reported that they were attending school
followed by 22 (22%) who described their occupation as housewives, 12 (12%) said they had no
occupation, 4 (4%) were classified as other and 14 were missing. On the issues of level of
education they were distributed as follows: 47 (42%) were in primary school; 49 (43%) were
attending secondary school; 13 (12%) were in high school and 4 (4%) were in tertiary
institutions.
Most of them were single as 79 (72%) reported that they were not married, 30 (27%) indicated
that they were married while 1 reported being widowed. The sample was too small and not
selected in a manner that could reflect the national situation. But it is a concern that as many as
30 adolescents, reported to have been married as this has implication on the level of formal
education they might have attained before they got into marriage. It is a common knowledge
that marriage goes along with several challenges that may deny these adolescents an
opportunity to pursue educational career. When asked if they had children 23 (24%) said they
had children while 75 (76%) reported that they did not have children and 16 were missing on
this question. All adolescents who reported to have children 18 had one child and four had two
children.
Adolescent-friendly health service characteristics: policies and procedures are in place that do
not restrict the provision of health services on any terms
When asked if they had ever come to the health facility and not been able to receive a
particular type of health service. Most of the adolescents said no, they had not experienced
such a situation 103 (94%) and only 7 (6%) said yes they had come across such a situation. The
adolescents who reported that they had come to the facility and not able to get the service,
one reported that the service required X ray and it was not available while one said that the
equipments that were required for HIV testing were not available. On the whole the
adolescents were able to get the services at the facilities. This is encouraging in terms of making
sure that adolescents do get required services at the health centres.
On whether there was any health service offered at the facility that they thought some groups
of adolescents might not be able to receive. The results that one hundred and four 104 (94%)
said no and only seven 7 (6%) said yes. Those who said yes seven of them felt that adolescents
who were between 10 to 15 years should not be given health facilities like contraceptives and
43
issues of family planning. The reason was that they were too young to be engaged in sexual
activities and thinking about families to plan. Furthermore, they reported that some
adolescents’ clients would need parental permission to get certain service and it would be
difficult for such adolescents’ client to seek permission from parents to get certain health
services particularly if they are related to birth control. This response is consistent with what
some facility providers said in relation adolescent’s clients who needed specifically
contraceptives. This concept is negating reality on the ground as literature has shown that
adolescents start sexual activities at the age of ten.
Health-care providers treat all adolescent clients with equal care and respect, regardless of
status
Adolescents reported that the health-care provider treated them in a manner that made them
feel comfortable or respected as one hundred and three 103 (94%) said yes and only seven 7
(6%) said they were poorly treated. Those who felt that they were poorly treated raised the
following issues: one said the doctor that attended to her health needs did not understand
Sesotho and there was no one to translate as a result there was communication breakdown
between the client and the service provider; two said the nurse was not listening to their
suggestion about the specific need they wanted, she wanted to provide what she thought was
needed, rather than what the clients actually wanted and one said he wanted a circumcision
procedure but he was told that he needed parental permission to that.
Support Staff Treated all Adolescent Clients with Equal Care and Respect of Status
The support staff as well as receptionists were reported to have treated the adolescents clients
with care and respect, as nearly all them reported that they were respected and made feel
welcomed and at home. However, there were few lonely voices that reported that they were
treated poorly. They said the receptionist was rude and not properly guiding them in filling the
necessary paperwork before they could see the service provider. She was just not interested in
clients, some elderly clients were not able to read and write but she just gave them papers to
fill and she never bothered nor cared to help them even though they were frustrated and
ended up in asking assistance among other clients. This is indeed a lonely voice that could be
speaking for many who are not happy with manner in which support staff as well receptionist
treat adolescents’ clients in their various institutions.
Policies and Procedures are Place that Ensure that Health are Either Free or Affordable
The adolescents reported that they were asked to pay for the services, as fifty three 53 (47%)
said yes to the question and fifty nine 59 (53%) said they were not asked to pay for the service
provided. The respondents who reported that they were asked to pay for services were asked if
44
they were able to pay for the service; forty four 44 (89%) said that they were able to pay for the
service and only five 5 (10%) were not able to pay for the service. All five adolescents who could
not pay were given service despite the fact that they were not able to pay. This is a very
important finding even though the respondents were too few to generalise that adolescents
were able to get services even if they were not able to pay. This finding is not consistent with
what the service providers said because they indicated that if adolescents were not able to pay
they referred them to social welfare for support and that implies that if they did not have funds
the may have problems in accessing services. The providers that offered services even if there
were no funds were those that had financial support either from the donor community or the
government itself.
The Point of Health service Delivery has convenient hours of Operation
When asked If they knew the days and times that the health facility was open fifty four 54
(57%) said yes, while forty one 41 (43%) said they did not know the days and times when the
facility was open while 19 did not respond. This should be a concern for all stakeholders if such
a large number of adolescents did not know the days and times when health services were
operating.
When asked if the working days and working hours of the health facility were convenient for
them forty four 44 (59%) said they were suitable and thirty two 32 (42%) said they were not
suitable for them. The latter scenario is consistent with what adolescents said in focus group
discussions where some raised the issue that the days and times were not suitable as they were
in school during those times. It is worth noting that a significant number of the adolescent
client felt that the operating hours were not suitable.
Adolescent Client are well informed about the range of Available Health Services an dhow to
obtain them
When asked to tell which health services were offered the following were raised: 40
adolescents mentioned contraceptives; 35 HIV testing; 23 family planning as a concept and its
importance; 23 raised HIV counselling; 12 pregnancy testing; 10 pre natal care; 5 post natal
care; and 4 immunization of children. Contraceptives rated high among services that were
offered by health facilities.
When asked how they heard/learned about the service the following were mentioned: 43
reported health facility; 18 heard from their parents; 11 from friends; 14 from the public nurse;
4 from teachers; 3 from village health worker; 3 from the radio and two reported that they had
read from the health pamphlets and posters.
45
Health Services they Need, and Support their Provision
In some traditionally oriented cultures parents act as barriers towards adolescents accessing
reproductive health services. In order to find out if this could be the case in Lesotho
adolescents were asked if they thought that their parents/guardians would be supportive of
their coming to health facility for reproductive health services. The findings show that 82 (80%)
reported that their parents would support them in accessing reproductive health services, 21
(20%) said that their parents would not be supportive of their going to the health facility to
access reproductive health services and 11 adolescents did not respond to the question. When
asked why their parents would not be supportive of them coming to health facility for
reproductive health service the common response was that reproductive health services were
meant for people who were married and accessing reproductive health services was an indirect
way of encouraging adolescents to engage in sexual activities. I must note that generally the
question was not answered by adolescents who had said their parents would not approve of
their access to reproductive health services.
There are some general misconceptions about certain reproductive health services; in order to
check if they exited in Lesotho. The study asked adolescents if there were some reproductive
health services their parent/guardian might not want to be provided directly to them. 58 (50%)
said yes and 56 (49%) said no. Those who said yes were asked to mention those health services.
22 said their parents would not approve of them having access to condoms; 13 family planning;
12 pills; 7 sex talks; 6 contraceptives; 3 injections and 1 pregnancy termination. It is of great
concern that some adolescents reported that their parents would not approve of their having
access to condoms when the government advocates availability of condoms as a way
combating HIV and AIDS which is a pandemic in Lesotho.
Most of the adolescents 100 (88%) said that they thought that other adults in the community
were supportive of adolescents coming to the health facility for reproductive health services.
Only 14 (12%) felt that other adults in the community were not supportive. Those who felt that
other adults in the community were supportive said the health facility was there to promote
good health among adolescents as well as general members of the community. It was also
there to provide appropriate information necessary for the general welfare of the community.
Those who felt that adult members of the community were not supportive of the health facility,
on the whole they felt that disapproval was purely based on ignorance about modern medicine
and ways in which adolescents could improve their life in general.
46
Some health services and health-related commodities are provided to adolescents in the
community by selected community members, outreach workers and adolescents themselves
There are certain health facilities that are provided to the community by various institutions
rather the health facility. In order to check if there were individuals or institutions that were
providing health services to the community besides the health facility the respondents were
asked if they were aware of health services that were provided in the community. 48 (45%) said
yes, they were aware of such health services and 58 (55%) said they were not aware of such
health services.
Respondents, who were aware, were asked what types of health services were provided. The
following health services were mentioned: contraceptives such as condoms, pills and injections
were mentioned by 15 adolescents; HIV testing and counselling was mentioned 17; injection for
cervical cancer 2; health education and circumcision was mentioned by 1. Adolescents were
asked to mention who provided health services and the following were raised: health provider
from the health facility was mentioned by 20 (36%) respondents; village health worker 31 (55%)
peer educator 5 (8.9%) and there were 58 cases that did not respond to the question.
Confidentiality is very important in encouraging and motivating adolescents to utilize health
services provided by the health facilities. In order to establish the existence or nonexistence of
confidentiality adolescents were asked if they believed that the information they shared with
the health-provider would be kept confidential. 89 (84%) believed that the information they
had shared with the health service provider would be kept secret, 17 (16%) believed that the
information would be disclosed. When asked to explain their responses the following general
themes emerged: 15 adolescents said since they had visited the health facility several times
they had not heard any one talking about their problems so they had no reason to believe that
information would be disclosed; 11 said they thought health service providers had taken an
oath not to disclose any information about their health clients; 26 said they had confidence
because in the consultation room there is client and the health service provider only. There
were also some lonely voices that believed the information could be disclosed because the
nurse was friendly to his relatives; and one reported that he/she had heard people talking
about her pregnancy even before it could recognised and there was a suspicion that the
information had been disclosed by health service provider. I must indicate that many
adolescents did not respond to this specific question.
When asked if they believed that all staff working at the health facility will keep their
information secret. 83 (79%) said they believed that staff will keep confidentiality and 22 (21%)
believed that staff would not keep confidentiality about health issues that affected them.
Adolescents who had confidence raised the following issues: 15 said professional people do not
47
discuss clients issues except in a situation where they want opinions from other professionals;
20 said staff in the facility were compelled by the oath they had taken not to disclose clients
health problems; 15 said they were serving too many people as a result it would not be possible
to remember individual clients health related issues; 15 felt confident because they had not
heard anyone talking about their health problems. Those who lacked confidence 8 said the staff
at the facility talked too much about client’s problems. There was a lonely voice that reported
that some members of the staff had friendly relationship with his parents, the feeling was that
information could be easily disclosed.
Adolescents were asked if they told a doctor something personal, others in the health facility or
community will find out, 40 (36%) said yes, 70 (64%) said no. It is a cause for concern if 36% of
the respondents felt that if they told a doctor something personal others would know about it.
39 (35%) adolescents reported that if they told a nurse about something personal others in the
facility and community would know about it, 72 (65%) believed that no one would know about.
The Point of Health Service Delivery Ensures Privacy
Adolescents were asked when they visited the health facility, did they believe that other clients
could see them and hear what they came for. The results show that 27 (24%) felt that other
clients could see them and hear what they came for, 85 (76%) said no to the question. When
asked to explain the following issues were raised: 16 said yes they could see me but they would
not know what one came for; 1 said it is well known that clients for a particular disease come
on a particular so it would be known what health service one needed; one said it is common
knowledge that certain health services deal with a particular disease so people would know
there is no secret about it; 1 said we live in small villages our health needs are known at the
village level even before we visit the health facility; 1 said it is common knowledge that if a
male visited the facility it is either he wants condoms or is going to get treatment for sexually
transmitted disease; if one was pregnant it would be seen so they is no confidentiality about it.
The responses show that the issue of confidentiality is a huge problem to such an extent that
clients no longer care about it as they feel that is generally known why one had visited the
health-service facility. They reported that the confidentiality is violated at the village level as
they know each other very closely.
When talking to the receptionist other people could hear what is being said, 38 (35%) reported
that they could be easily heard, while 70 (65%) said they could not be heard. On the issue of
interruption 25 (22%) said they had been interrupted and 88 (78%) had not been interrupted.
14 (12%) believed that others could hear their discussion with the health care provider when
they were in the consultation room while 99 (88%) believed that they could be heard.
48
Health care providers were reported to give full attention to adolescent clients as 102 (94%)
said they were given full attention and only 6 (6%) said they were not given full attention. The
similar scenario occurred when asked if the health-care provider seemed interested in what
they had to say as 102 (94%) said yes and only 7 said no. 81 (76%) felt that the health- care
provider respected their views while 25 (24%) felt that their views were not respected. Those
who said their views were respected were asked to give examples. The following were raised:
one said health provider understood her preference between injection and pills used for
contraception; one preferred to stay in the hospital during the last days of pregnancy and she
was allowed; she understood when the client requested to be examined in a room where there
was a door so that other clients could not hear the clients problems. This particular question
was not addressed by many respondents.
Waiting periods could discourage adolescents from attending health facilities if they had to wait
for long periods. In order to assess the state of the art adolescents were asked whether they
found the waiting times to see the health care provider reasonable. The results showed that 69
(61%) felt that the waiting periods were reasonable while 44 (39%) said they were not
reasonable.
When asked to explain their responses few respondents answered the question and those who
felt that the waiting periods were reasonable said they were able to get services within the
short period. Adolescents who were not happy reported that they waited for too long and this
interfered with their daily schedule as they had to put aside other things in order to wait for
health services. It should be of great concern to note that almost 40 percent of the adolescents
were not happy with waiting times. I strongly believe that in order to encourage adolescents to
use health services the waiting periods must be addressed.
When asked if the health-care provider referred them. The results showed that 34 (32%) said
yes, they were referred while 73 (68%) were not referred. Adolescents who reported that they
were referred were asked if it was explained why they were referred to another place. The
results showed that 24 (69%) were given explanations why they were referred to another place
while 10 (31%) said no it was not explained why they were being referred to another place. It is
also a serious concern that some adolescents were referred to some other places without
explanation. One strongly feels that it is critical that health-service providers should be user
friendly in order to attract adolescents.
When asked to explain their responses those who said that they were referred without
explanation raised the following issues: 2 said they were told that the reasons for referral were
written in their health books for service- provider where they were referred to; one said she
was simply told to go to another facility because she had refused to be tested for HIV.
49
Respondents who reported that they were given reasons for referral raised the following issues:
3 said they needed X ray and it was not available within the health-facility; 5 said the
medication needed was found at a place of referral and 6 said the services needed were at the
major health facility (hospital); 6 said the service health provider was also sick and unable to
function.
Most of the adolescents who were referred said that they were told where and when to go as
25 (73%) reported so and only 9 (26%) said they were not informed about where and when to
go.
The point of Health Service Delivery has an Appealing and Clean Environment
When asked if they found the health facility a welcoming place, the general picture was positive
as 89 (78%) indicated that surroundings were clean and welcoming while 25 (22%) felt the
surroundings were relatively poor; 98 (86%) said the receptionist area was clean 16 (14%) said
it was not clean; 87 (76%) reported that the waiting room was clean and welcoming 27 (24%
were not sure about the status of the waiting room and the toilets were also reported as clean
by 68 (60%) while 46 (40%) felt that the toilets were not clean and all respondents said the
consultation rooms were welcoming.
The point of Health Service Delivery Provides Information and Education through a Variety of
Channels
Adolescents were asked if they saw information/educational materials on topics of interest to
them during their visit to the health facility. The results showed that 86 (80%) saw the pictures
while 21 (20%) reported that they did not see any pictures in the facilities that they visited and
7 were missing. Adolescents who had seen the pictures were asked if the materials were useful.
The results showed that 88 (95%) felt that the materials were useful, 5 (5%) said materials were
not useful. When asked if the materials were easy to read, 88 (95%) said yes and 5 (5%) said
they were not easy to read. The materials were also interesting for adolescents to read as 88
(95%) said they were interesting to read and only 12 (13%) felt that they were not interesting to
read.
The information/education materials at the health facility were highly appreciated by most
adolescents. They were as good sources of learning for adolescents who visit the health
facilities. It could be encouraged that all facilities display such materials for adolescents to view
and read when they visit the health facilities.
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Adolescents are Actively Involved in Designing, Assessing and Providing Health Services
It is important to engage adolescents in designing as well as evaluating and providing health
services within their own environment. They were therefore asked if they were aware of
adolescents who were involved in contributing decisions about how health services should be
delivered to adolescents’ clients. The results showed that 41 (39%) were aware of the
adolescents that were involved in contributing decisions about how the process should go, 65
(61%) were not aware of the adolescents that were contributing some thoughts. The findings
showed that adolescents were not generally active in contributing thoughts or decision on how
health services of the adolescent client could be improved.
Those who said they were aware of adolescents who were contributing to decisions about how
health services should be delivered were asked what they did. The following issues were raised:
20 reported that those adolescents simply gave the public nurse feedback on how effective her
public lecturers with adolescents were; 16 said they were providing motivational talk to other
adolescents about avoiding general issues that may negatively affect adolescents’ health; 15
distributed condoms within their community and 6 were engaged in agricultural activities to
ensure that adolescents were producing food in order to have a balanced diet.
When asked if they would feel comfortable in making a suggestion to the staff for improving
the way in which health services were provided, the results showed that 75 (66%) were not
comfortable in making suggestions and 39 (34%) would make suggestions. When asked to
explain their responses the following issues were raised: 20 adolescents reported that they
were not well knowledgeable about issues of health as a result they would not be confident
enough to make meaningful suggestions; 15 said there were not very close to health-service
providers so they feared approaching them; 12 said if certain services were provided by their
age mates they would feel comfortable in making suggestions.
Adolescents who felt that they were comfortable in making suggestions went ahead and listed
some ideas that they thought were relevant for improving the way in which health services
were provided. The following suggestions were made: 3 said clients should be treated in a
respectful manner; 1 said waiting time should be shortened; 1 said increase the number of
professional health service providers; 1 felt that health providers should be trained in public
relation and how to treat clients with respect, 2 said toilets should be renovated; 2 said health
facilities should be opened on Saturday and Sunday in order to suit the needs of adolescents
who attend school and 10 said health facilities should educate adolescents about HIV so that
adolescents do not attach stigma on those infected with the virus.
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The Required Package of Health is Provided to Fulfil the Needs of Adolescents Either at the
Point of Health Service Delivery or Through Referral Linkages
When asked if they did receive health –services they needed to deal with their health concern
or health problem. The results showed that 96 (91%) of the adolescents were able to get the
service they needed and 10 (9%) reported that they were not able to get the facilities they
needed. Those who did not get the services were referred to another facility as indicated earlier
in the report. The common practice is to accompany clients that had been referred to major
health–service facility where they were attended for issues that were not available at a
particular health service.
Health-Care Providers have the Required Competencies to Work with Adolescents and to
provide them with the Required Health Services
Respondents were asked whether the health-care provider explained things in a way they could
understand. The results showed that 74 (84%) said that things were explained in a manner that
was easily understood while 14 (16%) felt that the explanation was not easily understood.
Those who said things were well explained raised the following points: 17 said the health
facility provider explained thoroughly the medication needed and when and how it should be
taken; 25 reported that the health-care providers were patient and generally accommodating
to all concerns that were raised. Those who felt that things were not explained felt that healthcare providers were under pressure to meet the needs all clients and as a result were not able
to explain in details and took so many things for granted.
When asked if the health care provider explained to them what check-ups/tests he or she was
doing. The results showed that 81 (81%) were thoroughly explained while 19 (19%) reported
that things were not well explained. The results of the check ups/tests were on the whole
explained as 83 (82%) reported that they were explained and only 18 (17%) said they were not
explained. What treatment was being proposed was also explained as 71 (71%) said it was
explained and 29 (29%) felt that it was not explained. The health-care providers did not seem to
discuss the pros and cons of different approaches as 59 (54%) said yes and more or less the
same number 50 (46%) said no.
When dealing with various health-service needs of the adolescents, it is important sometimes
to give them treatment of their own choice where necessary. In order to check if this practice
existed in health services the adolescents were asked if the health-care providers asked them
which treatment they preferred. The results showed that generally adolescent were not given a
choice as 25 (23%) said there were preference while 83 (77%) said there were no preferences.
52
Health Care Providers are able to Dedicate Sufficient Time to Work Effectively with their
Adolescent Client
Generally adolescents reported that they did not have time to ask everything they wanted to
ask, as 49 (45%) reported that they had time to ask everything while 60 (55%) said they did not
have time to ask every thing. It is critical that adolescents have enough time to discuss health
issues with health-providers so that they could understand and have high appreciation of the
efforts undertaken to improve their general welfare as a whole. When asked if the health care
provider answered their questions in a relaxed manner or did he/she seemed rushed and
hurried to see the next patient. The results showed that 55 (73%) said yes and 20 (27%) felt that
their questions were not addressed satisfactorily as the health providers were in a hurry to see
the next patient.
The Point of Health Service Delivery has the Required Equipment, Supplies, and Basic Services
Necessary to Deliver the Required Health Services
Respondents were asked if the health facility had all medicines and supplies to deal with their
needs, the results showed that 64 (58%) reported that there were enough supplies and 46
(42%) said the supplies were not sufficient. The nature of the study is such that an inference
cannot be made but it is definitely a cause for concern that so many adolescents reported that
health-service supplies were not sufficient. In order to improve and encourage adolescents to
access health- services efforts should made to ensure that basic health service needs are
available at the health facilities.
In order to solicit the opinions of adolescents about how the Ministry of Health and Social
Welfare could improve the health facilities, adolescents were asked to mention what in their
opinion would be an ideal health facility. The following points were raised: 60 adolescents said
they wanted a clean environment with clean and well caring staff; 55 said an ideal centre is one
that opens at the times that are suitable for most of the adolescents and should have all health
services required; 23 felt that an ideal health facility is the one where health service provider
respects them and talk to nicely; 15 said they would want to have an efficient health; 2 said
they would want a health facility where students are given priority over others so that they
could get service and go to school; and finally there was a lonely voice that said it would want a
facility that is served by a medical doctor.
It is important to ensure that adolescents fully participate in issues that affect their general
welfare, for example, communicating with others about health needs, as well as recruiting
others to participate in ensuring that adolescents have knowledge and access to good health. In
order to assess issues that would encourage adolescents to take lead in ensuring that they
53
actively participate in activities that will promote good health. Adolescents were asked to
mention what would motivate them to be involved in health service issues. The question was
not addressed by many adolescents but few that responded raised the following issues: 3 said
the communities should form adolescent health support groups; 2 said they wanted to be
trained in public speaking so that they could be able to mobilise others to avoid activities that
would hurt them.
There is a general observation in Lesotho that females tend to access health services more than
males. In order to verify if that existed among adolescents, the question was posed as to which
gender in their opinion accessed health services than the other. The results showed that in
adolescents perceptions there was no difference as 55 said female and 56 reported that the
services were accessed by both groups.
Data from Village Health Workers
Characteristics of Village Health Workers
Fourteen village health workers were interviewed for this study, they were distributed within
villages that were served by health facilities as follows: St. Peters five participants were
interviewed; St. Joseph one; Scott hospital four; Motebang hospital one; Machabeng hospital
one; Litsoeneng health clinic one and Mafeteng hospital one. The respondents were also
distributed in districts as follows: Botha Bothe had five respondents; Leribe one; Berea one;
Mafeteng one; Maseru five and Qachasnek one. The three regions were represented as follows:
ten were located in the lowlands; three in the foothills and one in the mountains. All of them
were females. The number of years they had served as village health workers were very diverse
as it ranged from one year to 20 years. The dates in years in which they were offered training
were also diverse the earliest being 1992 and latest being 2011.
Eleven village health workers reported that they were offering health services to adolescents in
their communities. The commonly offered health service was health education as it was
reported six village health workers. Unfortunately, interviewers did not probe enough to
unpack what was actually meant by health service education. Health education was followed by
agricultural lessons as it was mentioned by four respondents. Family planning, prevention of
sexually transmitted and HIV and AIDS were reported by three village health workers.
Adolescents’ clients were also encouraged to go to the facility centres for HIV testing when a
village health worker observed that there were some signs that one could be infected. It is a
concern that two village health workers reported that they encouraged adolescents’ clients to
go and test when there were already symptoms of the disease. This is contrary to the national
policy where every body in the country is encouraged to know their status.
54
The major health needs of the adolescents’ client were a health facility that would be close to
the community. The other issues that were mentioned by lonely voices were school drop outs
that were high in the community; high unemployment that devastated the moral and physical
health of the adolescents’ population; counselling on issues of HIV and AIDS.
Training needs as mentioned by the village health workers were also diverse and did not give a
common consensus as individual voices raised the following: motivational speaking so that one
could be able to influence adolescents to change behaviour; first aid; how to approach
adolescents so that one could easily change their behaviour; thorough understanding of
reproductive health so that one could be able to serve as a reliable sources of information for
adolescents at the village level. The other perception was that village health workers should be
provided with printed material that addresses issues of adolescents’ health and they should
serve as distribution points rather than give them training on reproduction health care and
education as they do not have sufficient educational background to absorb critical issues of
health reproduction.
All village health workers reported that there were cases that they had to refer to the main
facility service area. The major referral cases were pregnancy as it was reported by six village
health workers; sexual abuse was mentioned by five. The following were raised by lonely
voices: suspected tuberculosis cases; male circumcision; HIV testing; sexual assault and sexually
transmitted disease.
Twelve village health workers reported that adolescents were not participating in promoting
health services in the communities and one said that adolescents were participating. The lonely
voice that reported adolescents’ participation mentioned vegetable production in order to
promote health through appropriate eating and sensitising others about issues of good health
and delayed sexual activity.
Data from Policy Makers
The interviews were held with two officers from the Ministry of Health and Social Welfare, one
officer from the Ministry of Education and Training, one officer from the Ministry of Gender
Sports and Recreation and finally three officers were interviewed from the Child and Gender
Protection Unit of the Ministry of Home Affairs.
During the interviews it became clear that the Ministry of health and Social Welfare in
collaboration with the Ministry of Education and Training were working on a curriculum that
would infuse sexuality education for all adolescents. The schools were seen as the most
valuable place as there is a policy that says all adolescents must have access to formal
education. It was therefore apparent that Health information that is channelled through
55
schools will be accessed by a larger population of the adolescents. However, it was noted that
the concept of contraception within the school had to be addressed with a great care as the
cultural aspects and religious believes would be offended. It was suggested that it would rather
be known than be a service that is offered within the school environment, especially high
schools and primary schools.
The Ministry of Health and Social Welfare had to develop the concept of adolescents’ health
corners or adolescents friendly health services in order to ensure that package(s) of adolescent
health services were accessed by adolescents without any barriers. It was reported that offering
adolescents health services within the normal structures of the health services was creating
problems for adolescents as there were cases when they feared parents or senior staff
members so the idea of an adolescents’ corners was to create an environment that was
conducive to the health needs of the adolescents. It was reported that there was a policy on
access to condoms, contraceptives and emergency contraception for adolescents and the
practice was that they were accessed at the health-service facilities, especially those that were
friendly to adolescents.
There were laws that prohibit forced marriages (abduction, elopement) and polygamy, but the
main obstacle was that the nation at large did not know about its legal rights so the practice still
continues. It was reported that this is still common in the rural areas where people still have
limited access to information but where people know their right the practice is limited. It was
noted that there was no policy on male circumcision by non medical traditional institutions,
however, it was noted that in terms of HIV and AIDS the issue of circumcision was confusing as
there were people who thought circumcision would prevent HIV infection. It was reported that
traditional institutions had been advised in various health fora that each adolescent should
have his own racer blade for traditional circumcision.
It was reported that adolescents start sexual activities at the age of ten, and it was quickly
pointed out that age is not important because the policy says adolescents should have access to
all necessary health services as long as the health service is within the laws of Lesotho. The
policy also encourages access to HIV testing prevention care and treatment and it was
mentioned that the policy discourages any form of discrimination against people who are
infected with HIV.
Adolescent health is included in pre-service training of health workers even though one would
not say in all categories. It was also noted that the depth of addressing the topic may not be
known but it is certainly addressed. There were mechanisms for periodic dialogue and
collaboration between health worker training institutions and health organization
establishment providing health services to adolescents. It was pointed out that within the
56
Ministry of Health and Social Welfare there was an office that has been established for
coordination of issues related to adolescent health.
The village health workers and some adolescents ensure that adolescents had access to
condoms at the local village level. It was emphasised that the source of health service is still the
facility but distribution has been decentralised to the community at the village level.
The policy on routine data on service-utilization in clinics and hospitals is there but the main
problem has always been application as there were units across the nation that were supposed
to collect these information but the problem has always been poor data storage and it is
relatively difficult to access such information when needed. It was reported that there were
some reports on mortality and disease surveillance even though they were not as periodic as
they should be; reference was made to some old studies. The surveys on knowledge, attitudes
and behaviour related to substance use; mental health and violence were undertaken but not
as periodic as the Ministry of Health and Social Welfare would want. The main reasons
advanced for not undertaking regular reviews was finance as well as limited expertise within
the ministry. On issues the related to age specific maternal mortality and morbidity,
pregnancy/birth rates, by age; pregnancy-related mortality and morbidity and STI/HIV by age, it
was reported that these statistics should be available periodically but the main problem was
data management and administration of data. It was noted that data should be available but
the problem is the manner in which it is stored which means that one may not be able to access
it immediately as and when wanted.
The policy makers felt that it was difficult to access accurate statistics on age of initiation of
sexual activity within and outside marriage, use of contraception, and levels of non-consensual
as these behaviours can only be studied through opinions of those who are willing to
participate in the study. It was reported that there were many adolescents that had been
forced into sexual relation but who were not willing to come and report such behaviours to the
police and other law enforcement authorities. Data on accidents and injuries by age should be
available where data management was accurate and up dated.
Focus Group Discussion with Adolescents
On the whole adolescents reported that they had never been denied health services at the
facilities. However, there were voices that said “we were not denied a service but the service
provider who is a nurse is a very close friend of my mother I feared asking a reproductive facility
because I thought she was going to discuss the issue with my mother.” The second lonely voice
that emerged was that during the consultation a nurse left the client unattended in order to
accompany his/her friend who was going somewhere and the adolescent reported that he left
57
without being provided with a service because the service provider took a long time
accompanying his friend. There was also a lonely voice that reported that she was denied
health service she was requesting because she was told that was too young to engage in sexual
activities. The lonely voice could represent the voices of many therefore it is critical that those
who provide health services could take them into consideration and have a policy that would
address their concerns.
Adolescents on the whole agreed that health-care provider at the facility treated them in a
friendly manner. But there was a voice that reported that the facility provider did treat his
friend in a manner that made him/her upset because the friend was denied service because he
had abused alcohol and he was told that he could only get the service when he was sober. The
voice argues that the service required was a condom and he could not understand why one
would get a condom only when he was sober. The lone voice argues that his friend was treated
in this manner because the service provider had judged him as an adolescent who was engaged
in an activity that was not acceptable according the standards of the nurse in-charge of the
service.
There were cases where adolescents reported that receptionists and support staff treated them
well. But on the whole adolescents reported that they were not treated well by receptionists
and support staff. There were two themes that emerged throughout all the focus group
discussions. The first is that receptionist instead of simply registering their names they wanted
to know why the clients were there and what services they needed. Secondly they noted that
waiting times as a result of long lines were too long and friends of the receptionists and support
staff were always allowed to get services before others even if they arrived late at the facility.
The adolescents indicated that they felt that confidentiality would be compromised if
receptionists were allowed to know why they were at the facility. Adolescents also noted that
generally receptionists were just ordinary people who had not undergone professional training
and they felt that confidentiality would be compromised if receptionists were to know why they
were at health facility.
The issue of adolescents being denied health service at facility because they could not pay the
fees required emerged throughout all the focus group discussions. The adolescents emphasised
that some of them did not have money at all so they could not get any form of service. It also
emerged from the discussion that some adolescents were assisted by social welfare to pay for
the facility but the process that one has to go through in order to qualify for social welfare was
long and not easy at all. It is therefore apparent that finance is a barrier towards all adolescents
getting health services.
58
Adolescents generally knew the days and times when health facilities were opened but they
complained that the services were not offered at the times stipulated. They reported that there
were always delays caused by service providers who did not begin work on time. Adolescents
throughout the districts reported that the days and times were not suitable for them as they
were in schools during those days and times. It was noted that weekends (Saturday and
Sundays) would be appropriate for them and they suggested that from Monday to Friday they
would prefer services at 5:00pm that is after school.
Adolescents reported that they knew what reproductive health services were and they
reported that the following reproductive health services were provided: emergency
contraceptives; contraceptive; pregnancy testing; HIV testing and counselling; STI treatment;
family planning; sex and sexuality education; body changes during puberty and management of
relationship with the opposite gender. It seems adolescents knew what reproductive health
meant.
Adolescents in one voice indicated that parents would be supportive of their coming to the
facility for reproductive health services. However, their views were divided when it came to the
issue of contraceptives and abortion as there were voices that said parents would allow them
to get any required service and others exclusively said their parents would not allow them to
get contraceptives and abortions. The issue of abortion is not critical as abortion is not
permitted by law in Lesotho. The issue related to denying adolescent contraceptive is
controversial and calls for the intervention of the policy that dictates that adolescents have a
right to access any form of reproductive health service. There was a general consensus that
parents would not want their adolescents to be provided with contraceptives because they do
not want their children to be sexually active. However, there was a view among adolescents
that some parents did appreciate the use contraceptives by the adolescent but were under
pressure from the societal norms and expectations where parents were not supposed to
encourage their children to engage in sexual activities. It was reported that some adults in the
community were supportive of adolescents coming to the health facility for reproductive health
services because they were aware of high teenage pregnancy and they believed that
reproductive health services could be a solution to the problem. On the other hand there were
those who felt that the use contraceptives would promote or encourage adolescents to
willingly engage in sexual activities.
In order to assess if there were other bodies providing health services within communities
besides the regular health facility adolescents were asked to discuss if there were such
organizations or individuals. The adolescents said yes, especially with regards to the availability
of condoms. The condoms were supplied by various institutions such as the Red Cross and
59
other donor agencies through grassroots leadership. The other health services provided to
adolescents were mobilising them to produce vegetables so that they could eat well. The last
issue that emerged was the formation of adolescents clubs where they discuss issues of
improving their health and engaging in activities that will help them to work hard towards
building a better future for themselves.
Focus Group Discussion with Parents
The main objectives of the focus group discussion were to find out if parents or community
members understood the benefits that adolescents will gain by obtaining the health services
they need, whether they supported their provision and the efforts that have been made by
health facility to educate community about health services for the adolescents. The data
obtained is analysed qualitatively by reporting themes that emerged from the focus group
discussions through out the villages that were within the catchment of the sampled health
facilities.
There was a general consensus among parents that adolescents needed reproductive health
services. The common reason given by parents was that they needed information about
reproductive health services because they were sexually active. The parents were lamenting
that these days’ adolescents started sexual activities too early and to deny them services and
thorough information about reproductive health services would be promoting social injustice as
they would continue indulging in sexual activities without appropriate information. They agreed
that it would be in the interest of adolescents and the nation at large if adolescents were
provided with reproductive health services as they will make correct choices about their life
which may contribute towards a better future for the adolescents.
The above response poses some challenges for the Ministry of Health and Social Welfare and
other line ministries as it implies that parents were of the opinion that reproductive health is
only limited to sexuality. The concept is broad and inclusive of other critical aspects of
adolescents’ development and it should not be limited to sexuality as parents seem to
understand it. It should be clearly indicated that an adolescent that has accurate information is
likely to make correct choices regarding health in general.
Education on teenage pregnancy was a theme that emerged throughout the discussions and it
was generally agreed that even though it was discussed it was highly common among
adolescents in Lesotho. The second theme that ran across all focus group discussion with
parents was the availability of prenatal care and assistance for adolescents. The third theme
was that family planning concepts were taught to adolescents and necessary contraceptives
60
were made available to adolescents in general. The issues of HIV testing especially for pregnant
adolescents emerged throughout parents focus group discussions.
On the issue of whether there were certain reproductive health services that adolescents
should not receive at the health facility. There were generally two views that were presented
by parents across the districts. Some voices agreed that while contraceptives were important
and useful for delaying pregnancy among adolescents but if they were used too early they may
sterilise adolescents. It was therefore cautioned that adolescents should not be provided with
other forms of contraception rather than condoms. It was generally agreed that condoms were
appropriate for preventing sexually transmitted diseases as well as pregnancy therefore they
should be made available to all adolescents.
However, there was a lonely voice that argued strongly that adolescents should be taught
about the biological and physical changes that occur within the adolescent stage but they
should not be provided with any form of contraception as that would violate cultural norms and
encourage promiscuity among adolescents in general. The voice lamented that parents have
lost control over adolescents because of the free supply of contraceptives in all parts of the
country. The lonely voice reiterated that adolescents should be helped to focus on issues
related academic improvement at school rather than be supplied with contraceptives. It must
be noted again that this voice could represent many voices that do not understand that
reproductive health services do not necessarily mean sex education and provision of
contraceptives only. It is again a challenge for those who are charged with responsibility of
educating the community about health issues to address some these misconceptions. There
were also voices across the parents that strongly felt that adolescents must be given all
available forms of health services and there should be no form of discrimination what so ever.
On the efforts that the facility made to inform the community about the types of services
adolescents needed, there were two views that emerged across all discussions. The first view
was that individuals within the health facilities were not making enough effort to sensitise the
community about health services that could be provided specifically to adolescents. There was
a general agreement that they had heard about the services from other members of the
community rather than the staff working at the facility. The second view noted that the health
facilities made significant efforts to make adolescents aware of the services that could be
provided to adolescents. Parents agreed that the health service facilities staff were visiting
schools and sensitising adolescents about services. It was agreed that they were mobilised
through local gatherings called “lipitso” and women groups association. There were also voices
that said the health facilities had done their work successfully but the problem was with
61
parents who were not willing to inform their adolescents about the services that were available
at the health facilities.
The parents focus group discussion on the issue of what efforts have been made to inform
adolescents about aspects of reproductive health were not very clear as there were voices that
said they were taught these issues at schools without making reference to the issues they were
referring to. There were also voices that said adolescents were taught reproductive health at
the facility when they were pregnant and immediately after delivery.
Summary of Findings
Adolescent Formal Education
The high level of formal education has a positive impact on adolescents’ health in general. The
nation that invests on adolescents’ education indirectly improves their standard of health. The
literature showed that despite the efforts that have been made to remove financial barriers in
primary school there were many adolescents who dropped out of the school before they
completed the primary school phase. The reasons were many but the outstanding were
traditional practices that were not in harmony with the formal school as many adolescents
dropped out of the school to attend such practices. The second was attributed to high wastage
within the system as many were retained in grades due to failure which in most cases
discouraged adolescents to continue with their educational career. The third was that many
parents were not able to finance secondary education. The last and most critical was poor pass
rates which did not allow many adolescents to get access to tertiary education. It was noted
that without relevant and appropriate education adolescents had to face hard challenges of life
which normally lead them into behaviour that have negative impact on their lives.
The lower level of education contributes significantly to high rates of unemployment which
significantly affect adolescents. The unemployment rate of Lesotho is estimated at 47 percent.
The figures include adolescents and it is clear that unemployed youth is bound to have serious
problems that impact negatively on health.
Adolescent Pregnancy
Sexual activity among adolescents starts too early and it is not known exactly when it starts as
some studies reported that it starts as early as ten years. The Government of Lesotho, 2006
reported that sexual intercourse starts as early as the age of 12 for males and 14 for females
and increases to nearly 50% by age 17. It is also noted that young girls have their first sexual
intercourse with partners that are by far older than themselves. Studies also show that despite
the high awareness of condoms adolescents were indulging in sex without the use of condoms.
62
The was no accurate statistics on adolescents who were using contraceptive as it is still not yet
morally accepted in a society at large for adolescents to have free access to contraceptives.
Secondly the health services that one uses are a secret between the service provider and the
client. Early pregnancy has many negative consequences for adolescents as they are normally
expelled from school and in some cases they are rejected by their parents. It was also noted
that the early pregnancy traumatise them as there are no counselling services for these young
people.
HIV/AIDS Sexually Transmitted Disease
Lesotho is the third country in Southern Africa and the world with highest burden of HIV and
AIDS and with an estimated adult prevalence of 23 percent among the 15-49 groups. The
country also has high orphans as a result of HIV pandemic. The Sentinel Surveillance data
indicates that the prevalence among adolescents aged 15-19 years was 8.9 percent in 2009.
Further the reports noted an increase in prevalence among the age group of 20-24 from 24.4
percent in 2007 to 24.9 percent in 2009.
Mortality and Morbidity During Pregnancy and Child Birth
Despite the fact that antenatal care is provided at different levels, the country still has a high
maternal mortality rate, estimated at 762 per 100, 000 live births, and an infant mortality rate
of 72 per 1 000 live birth. The main factors contributing to this situation among adolescents
were lack of knowledge regarding the importance of early attendance, denial of the pregnancy
by the boy and living the girl traumatised and not willing to share her agony with parents, the
fact that sex outside of marriage in Lesotho is not acceptable discourages adolescents to attend
the health services.
Maternal mortality ratio is very high and has almost tripled over a period of 8 years. It has
increased from 282/100,000 live birth in 1996 to 419/100,000 live birth in 2001 and
762/100,000 in 2004. Neonatal mortality increased from 44/1000 live birth while infant
mortality rate increased from 75/1000 to 91/1000 live birth over a five year period in 2004.
Traditional Practices
There are some traditional practices that have a negative impact on adolescents’ health. The
practices are rooted in the cultural norms and societal norms. In Lesotho there are still some
pockets of forced marriages. For example, it is common in Lesotho for an adolescent to be
forced into marriage through abduction. It is highly unlikely that someone that has been forced
into marriage can discuss contraceptives and use of condoms with that kind of a partner.
Practice such as lobola “bohali” deny women equal rights to talk about sex and sexuality with
63
their partners as the practice gives one authority over the other. Traditional circumcision
schools also put adolescents’ health at a high risk of being infected with various diseases. The
practice also denies adolescents an opportunity to further their academic education as the
system is not harmonised with the formal school system.
Nutrition
The nutritional status of adolescents could only be assessed and observed within the context of
the country as whole. Since 2000 Lesotho has experienced unprecedented levels of acute food
insecurity. Only 30 percent of food needs are covered by domestic food production, the rest
being supplemented by food aid and imports. The accurate statistics on nutrition of adolescent
is difficult to come across as there has not been a study that exclusively focussed on the
adolescents. The nutritional status of adolescent could only be inferred on those who attend
clinics for various health problems. However, it has been observed in various formal schools
that there were many adolescents that were not eating properly due to food insecurity at
home. Secondly due to HIV and AIDS pandemic there are many households that are headed by
adolescents without any financial support to secure food. It is therefore an educated theory
that adolescents are facing nutritional challenges.
Rape
It is difficult to come up with accurate statistics of rape as it is a sensitive and painful experience
and many people prefer not to disclose the experience, especially where if it happened with
people that were related. Rape is common among adolescents even though it could not be
quantified. The review of some court cases and local news papers indicate that rape is indeed
common. It takes place even among people who have relationships and those who simply
perceive women as sex objects that can be abused as and when they so desire. The other factor
that may complicate accurate information about rape is that in Lesotho the definition of what
constitute rape is often unclear to the rape survivors or their families. It is not clear if females
can rape males or if a husband can legally be said to have raped his wife or a man his lover,
especially if the two of them had previously been having sexual intercourse.
Abortion
It is widely believed that there is a high prevalence of both spontaneous and induced abortions
among adolescents. However the precise statistics of these events is not known, except those
that end up in hospital due to complications resulting from the termination. The low use and
sometimes inaccessible contraceptives among adolescents contributes to high rates of
unwanted pregnancies which encourage abortions among adolescents. Abortion is illegal in
Lesotho and this encourages some adolescents to use extremely dangerous methods to
64
terminate unwanted pregnancies. The latest published facility based survey indicated that 13
percent of all abortions seen were among adolescents. It must indicated that these statistics
might highly under estimate the magnitude of the problems as some do not go to the facility at
all due to the fact that abortion is illegal and morally wrong within the context of Lesotho. It is
therefore in order that cases of abortion could be higher than estimated through the facility
records.
Substance Abuse
Substance abuse is common among adolescents in Lesotho. The smoking of cigarettes and
tobacco is extremely high among adolescents. In Lesotho both traditional and modern alcoholic
drinks are available to any one who has money to buy it regardless of the age. The most
common substances abused by children as young as ten years are cigarettes and tobacco,
alcohol, marijuana and recently some adolescents seem to have access to other serious drugs
that were not originally available in Lesotho.
Violence
Violence against adolescents in Lesotho is common and it comes in different forms. The first
and the most common is the actual physical assault against adolescents. This happens in the
family, schools and in the society at large. It is common in Lesotho to physically assault
adolescents with the hope that assault will correct the undesired behaviour and there are no
laws that directly protects adolescents against this form of violence. Sexual violence is common
as there are many cases of rape and traditional practices that allow forced marriages. In schools
corporal punishment is still practiced despite the fact that it is not allowed by law. Domestic
violence is also common and victims of such violence are always reluctant to seek protection of
the law for various reasons.
The Situation of Adolescent Health Services
Adolescents are generally served by all health facilities in the country but the Ministry of Health
and Social Welfare realised that there were some services that adolescents would better access
in a health facility that is focussing mainly on adolescents’ needs. In 1999 adolescent friendly
health services (adolescent health corners) were established in Leribe, Maseru and Mafeteng.
The innovation was extended to other districts and health services in the country.
A study was commissioned to review the effectiveness of these health corners. The results of
the study showed that most of them were no longer in use even those that were used were
relatively performing below expectations as they experienced various problems. Among many
challenges that emerged the following were critical: the operating hours and days were not
65
suitable for adolescents as they coincided with school hours for most of the adolescents; the
location of the adolescent health corners were strategically appropriate as they were close to
the community, but space was limited and this compromised confidentiality and discouraged
adolescents to use the facility; posters, booklets and other critical documents that could attract
and inform adolescents were lacking within the adolescents health corners; the corners were
managed by staff members that were poorly trained in dealing with adolescents; certain critical
topics like reproduction, sexuality, HIV and AIDS as well as sexually transmitted disease were
not taught within the health corners.
The policies regarding health services for this particular group were not well disseminated
within the local communities and so they were not known.
Policy Documents
Ten policy documents that had a bearing on adolescent were reviewed and summarised
highlighting the main issues covered in the documents. The review of policy documents showed
the willingness and political commitment to address the adolescent health issues. The second
theme that emerged throughout the documents was that the strategies that were to be
implemented were not assigned budget and costs so it was relatively difficult to see how they
would be implemented. In terms of being documents that outlined the intention and
commitment one feels they were good documents.
Empirical Results
The working definition of an adolescent is 10 to 19 years but there was confusion among health
service providers as some years that were not within the 10 to 19 parameters were mentioned.
On the whole facilities did not have policies that discriminate against adolescent clientele
except one voice that reported that they did not offer abortion services but if it was legalised it
would offer such a service. Adolescents who may be less likely to receive services were those
who were mentally retarded, physically challenged, drug addicts and sex workers. This response
did not mean that the facility will deny these groups a service but they themselves may not take
initiative to demand health services.
Generally adolescents were not charged for specific health services at the facility, but there
were few that charged normal fees that were charged to all clients. The facilities which did not
charge any fees were supported by government or donor community. The health facilities were
also involved in community outreach services as they visited communities and school in
addressing their health needs.
66
While attempts were made to ensure that adolescents were given the same treatment, there
were voices that noted that it was ethically difficult to supplier adolescents that were below 12
years with condoms and other family planning needs.
The communities were generally supportive of the health facilities provided to adolescents, but
there were some mixed feelings when it came to reproductive health care as some felt that
some members of the community were not supporting such services. However, community
members who supported the principles actually brought their children for health services.
There were policies in place that guaranteed the client confidentiality but what specific policies
were saying was rather not known as they were referred to by names only.
The point of delivery to a certain extent ensures privacy as most facility managers reported.
However, that observation is negated by service providers and adolescents who reported that
they were often interrupted during the service delivery. Adolescents were not actively involved
in designing, assessing and providing health services as shown by data from adolescent
themselves and service providers who indicated that due to time pressure they were not able
involve them.
The referral procedure was understood but there were some adolescents that felt the
procedure was not fully explained as to why they were being referred at all. The service
provider in some cases simply wrote in the health book why one was being referred without full
explanation. On the whole the required package of health was provided to fulfil the needs of all
adolescents either at the point of health service delivery or through referral linkages. It was
observed that most of the facilities were able to meet the needs of the clientele but where
necessary referrals were made. Facilities knew about various ways necessary for client referral.
The use of evidenced-based protocols and guidelines to provide health services were limited as
in some other aspects of the health service such protocols were not shown. In cases where they
were shown that was done by few. On the whole the health facilities had a system for
maintaining an inventory and recording the amount of medicines and supplies in stock.
However, there were some cases where in the last six months there were some disruptions that
affected the services. The shortages were either in the form of medicine or some equipment
that was necessary for the facility to perform its functions effectively. Some service providers
did not have enough time for client due to pressure of work and the number of clientele that
they had to attend.
On the whole the College curriculum for both facility managers and service providers covered
some elements of adolescent health needs. The issues that were commonly addressed in their
curriculum were as follows: teenage pregnancy; sexually transmitted diseases; community
67
health education; how HIV virus is transmitted from one person to another; counselling
adolescents living with the virus; reproductive health; family planning; biological changes that
occurred during the adolescent stage; antenatal care and post natal care; behaviour change
among adolescents.
Both groups reported that in-service training on issues adolescents was very limited. Both
groups expressed the desire to participate in adolescents’ health related issues, specifically;
among others the following were raised: how to involve adolescents in taking care of
themselves; skill in counselling adolescents; current issues on reproductive health; how to
communicate with adolescents.
68
References
Government of Lesotho (undated). The National HIV and AIDS Testing and Counselling Policy.
Government Report.
Government of Lesotho, (2002). National Social Welfare Policy. Government Report.
Government of Lesotho, (2006).National Adolescent Health Policy. Government Report.
Government of Lesotho, (2009). National Reproductive Health Policy. Government Report.
Government of Lesotho, (2012). National Family Guidelines. Ministry of Health.
Government of Lesotho, 2005. Guidelines for the Management of Survivors of Sexual Abuse for
Lesotho. Government Document.
Government of Lesotho, 2010. National Guidelines for the Prevention of Mother to Child
Transmission of HIV. Government Document.
Kimane, I., Ntimo-Makara, M., Lebuso, M. (2008). Frameworks on Sexual and Reproductive
Health Issues and HIV in the Context of Young people: Consultancy Report
Kingdom of Lesotho, (2003). Lesotho National Reproductive Health Survey Analytical Report,
Volume 1 United Nations Population Fund.
Leedy, P. (2000). Practical Research in Education. New York: Sage publishers.
Lefoka, Nyabanyaba and Motlomelo, 2008. The Evaluation of Free Primary Education in Lesotho
(2000-2006. Consultancy Report.
Lesotho Government, 2010. Educational Statistics Bulletin. Government Report
Lesotho times 12 June, 2012. Registered News Paper.
Ministry of Education and Training, (2005). Educational Sector Strategic Plan 2005-2015.
Government Report.
Ministry of Education and Training, (2005). School Health Policy of Lesotho. Government
Report.
Motlomelo, S., Sebatane, E.M. (1999). Adolescent Health Problems in Lesotho.
69
Moyo, I.M., (2008). Capacity Assessment of Adolescent Friendly Health Services in Lesotho.
Consultant Report for Ministry of Health and Social Welfare and UNICEF.
The Examination Council of Lesotho, 2012. A Compilation of Yearly Students Results. Council
Report.
The Kingdom of Lesotho, (2011). National HIV and AIDS Strategic Plan 22011/12-2015/16.
National AIDS Commission.
The World Bank, (2008). The World Bank’s Commitment to HIV/AIDS in Africa our Agenda for
Action, 2007-2011. Washington: CD, World Bank.
The World Health Organization. (2003). Making Health Services Adolescent Friendly Developing
National Quality Standards for Adolescent Friendly Health Services.
UNAIDS, WHO, (2006). AIDS EPIDEMIC update. UNAIDS
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Appendix A
Interview Guide for Adolescents
Demographic Information
1.
2.
3.
4.
5.
6.
7.
8.
Name of Facility _______________________________________________
Name of District: 1 Botha-Bothe 2 Leribe 3 Berea 4 Maseru 5 Mafeteng 6 Qachasnek
Location: 1 Urban 2 Rural
Geographical Location 1 Lowland 2 Foothill 3 Mountain
Gender
1 male 2 female
How old are you? ___________
Current occupation: Current Occupation _________________________________________
What is your highest level of education 1 primary 2 secondary 3 high school 4 vocational 5
tertiary
9. What is your marital status? 1 single 2 married 3 widowed 4 divorced 5 separated
10. Do you have children? 1 yes 2 No
11. If yes, how many children do you have? __________________________________________
Adolescent-friendly health service characteristics: policies and procedures are in place that do not
restrict the provision of health services on any terms
12. Have you ever come to this health facility and not been able to receive a particular type of
health service? 1 yes 2 no
13. If yes, do you know why you could not receive the health service?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
14. Are there any health services offered at this facility that you think some groups of adolescents
might not be able to receive? 1 yes 2 no
15. If yes, explain which health services and what groups of adolescents might not be able to
receive?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
71
16. Why do you think that such an adolescent might not receive that health service(s)?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Health-care providers treat all adolescent clients with equal care and respect, regardless of status
17. Has the health-care provider treated you in a manner that made you feel respected? 1 yes 2 no
18. If no, could you explain?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Support staff treated all adolescent clients with equal care and respect regardless of all status
19. Has the receptionist treated you in a manner in which you wanted to be treated? 1 yes 2 no
20. If no, please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
21. Did the receptionist make you feel comfortable? 1 yes 2 no
22. If no, please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
72
23. Have other support staff treated you in a manner in which you want to be treated? 1 yes 2 no
24. If no, please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Policies and procedures are in place that ensure that health are either free or affordable
25. Were you asked to pay for health services? 1 yes 2 no
26. If you were asked to pay for health services, were you able to pay? 1 yes 2 no
27. In case you could not pay, did you receive the health services any way? 1 yes 2 no
The point of health service delivery has convenient hours of operation
28. Do you know the days and times that the health facility is open? 1 yes 2 no
29. Are the working days and working hours of the health facility convenient for you? 1 yes 2 no
Adolescent are well informed about the range of available reproductive health services and how to
obtain them
30. Could you tell me which reproductive health services are offered at this health facility?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
31. How did you hear/learn about these services?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Health services they need, and support their provision
73
32. Do you think that your parents/guardians would be supportive of you coming to this health
facility for reproductive health services? 1 yes 2 no
33. If no, explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
34. Are there some reproductive health services your parent/guardian might not want to be
provided to you?
35. If so, which ones?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
36. Do you think other adults in the community are supportive of adolescents coming to this health
facility for reproductive health services? 1 yes 2 no
37. Please explain?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Some health services and health-related commodities are provided to adolescents in the community
by selected community members, outreach workers and adolescent themselves
38. Are you aware of any health services that are provided to adolescent in the community that is
outside health facility? 1 yes 2 no
39. If so, what type of health service is being provided?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
74
40. Could you tell me who is providing the health service? 1 health care provider from the health
facility 2 Village health worker 3 Peer Educator 4 other
41. Do you believe that the information you shared with the health-provider will be kept
confidential? 1 yes 2 no
42. Please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
43. Do you believe that all staff working there will keep your information confidential? 1 yes 2 no
44. Please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
45. If you tell a doctor something personal, others in the health facility or community will find out?
1 yes 2 no 3 not sure
46. IF you tell a nurse something personal, others in the health facility or community will find out?
1 yes 2 no 3 not sure
The point of health service delivery ensures privacy
47. When you visited the health facility, did you believe that other clients could see you and hear
you, and know what you came for? 1 yes 2 no 3 not sure. If yes please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
48. When you were talking to the person at the reception other people could hear you? 1 yes 2 no 3
not sure
49. Did anyone interrupt your discussion with the health-care provider? 1 yes 2 no 3 not sure
50. Do you believe that others could hear your discussions with the health care provider when you
were in the consultation/examination/treatment room? 1 yes 2 no 3 not sure
75
Health-care providers are non-judgmental, considerate, considerate, and easy to relate to
51. Did the health-care provider give you his/her full attention? 1 yes 2 no
52. Did the health-care provider seem interested in what you had to say? 1 yes 2 no
53. Did the health-care provider respect your opinion and decisions even if they were different from
his or hers? 1 yes 2 no
54. If yes, please give an example
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
55. Did the health-care provider treat you in a supportive and considerate manner? 1 yes 2 no
The point of health service delivery ensures consultations occur in a short waiting time, with or
without an appointment, and (where necessary) swift referral
56. Have you found the waiting times to see the health-care provider reasonable? 1 yes 2 no
57. Please explain your response
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________
58. Did the health care provider refer you to another place? 1 yes 2 no
59. If yes, did he/she explain to you why you were being referred to another place? 1 yes 2 no
60. Please explain your response
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
61. If yes, did he/she explain to you where and when to go? 1 yes 2 no
The point of health service delivery has an appealing and clean environment
62. Did you find the health facility a welcoming place to come to?
Surroundings ________________________________________________________________
Reception area ____________________________________________________________
Waiting room _____________________________________________________________
76
Toilets _______________________________________________________________________
Consultation room/examination room _______________________________________________
The point of health service delivery provides information and education through a variety of channels
63. Did you see information/educational materials on adolescent health topics during your visit to
the health facility? 1 yes 2 no
If yes, were the materials useful? 1 yes 2 No
Were they easy to read?
1 Yes 2 No
Were they interesting to read
1 yes 2 No
Were day interesting
1 Yes 2 No
Adolescents are actively involved in designing, assessing and providing health services
64. Are you aware of adolescents who were/are involved in contributing to decisions about how
health services should be delivered to adolescent clients? 1 yes 2 no
65. If yes, what did they do?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
66. Do you believe that you could make a suggestion to the staff for improving the way in which
health services are provided? Please Explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The required package of health care is provided to fulfil the needs of adolescents either at the point of
health service delivery or through referral linkages
67. Did you receive the health service you need to deal with your health concern or health
problem? 1 years 2 no
68. Were you referred to another health facility for health facility for health services not available at
this one? 1 yes 2 no
69. If yes, what did the health-care provider do to ensure that you got the services you have been
referred for?
_____________________________________________________________________________________
_____________________________________________________________________________________
77
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Health-care providers have the required competencies to work with adolescents and to provide them
with the required health services
70. Did the health –care provider explain things in a way you could understand? 1 yes 2 no
71. Explain your response
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
72.
a.
b.
c.
73.
Did the health care provider explain to you the following:
What check-ups/tests he or she was doing? 1 yes 2 no
The results of the check ups? 1 yes 2 no
What treatment he or she was proposing and why? 1 yes 2 no
Did the health care provider discuss the pros and cons of the different approaches with you?
1 yes 2 no
74. Did the health-care provider ask you which treatment option you preferred? 1 yes 2 no
Health-care providers are able to dedicate sufficient time to work effectively with their adolescent
clients
75. Did you have time to ask the health-care provider everything you wanted to ask? 1 yes 2 no
76. Did the health-care provider answer your questions in a relaxed manner or did he/she seem
rushed and hurried to see the next patient?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The point of health service delivery has the required equipment, supplies, and basic services
necessary to deliver the required health services
77. Did the health facility have all medicines and supplies to deal with your needs? 1 yes 2 no 3 not
sure
78. What would be your ideal health facility?
78
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
79. What would motivate you to be involved in health services issues?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
80. In your opinion which gender access health services facility (boys or girls and why?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
79
Appendix B
Interview guide for facility Manager
Demographics:
1.
2.
3.
4.
5.
6.
Name of Facility: _______________________________________________
Name of District: 1 Botha-Bothe 2 Leribe 3 Berea 4 Maseru 5 Mafeteng 6 Qachasnek
Location: 1 Urban 2 Rural
Geographical location 1 Lowland 2 Foot hill 3 Mountain
Gender: 1 Male 2 Female
How many years have you been a manager at this facility? ___________
Adolescent-friendly health service characteristics:
Policies and procedures are in place that do not restrict the provision of health services on any terms
7. In your opinion what is an adolescent?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
8.
Are there certain polices or procedures at this facility that might restrict the provision of health
services to some adolescents, such as those who are less than a certain age; those who are not
married; or those who belong to a certain group, such as people living or working on the street?
9. If so, could you describe what these policies or procedures are?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
10. Can you describe the characteristics of some adolescents who may be denied services?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
80
Policies and procedures are in place that ensure that health services are either free or affordable to
adolescents
11. Are adolescents charged for specific health services at this facility? 1 Yes 2 No
12. If yes, please give us a list o the health services provided and the charges for each
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
13. If no, why and how do you sustain the services?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
14. Are fees for adolescent clients less than fees for adult clients? 1 Yes 2 No
15. Do you provide concessions for clients who cannot afford to pay for health services? 1 yes 2 No.
Please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The point of health service delivery has convenient hours of operation
16. What are the working days and working hours of the health facility?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
17. Are the working days and working hours of the health facility convenient for adolescents? 1 Yes
2 No
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
81
Some health services and health-related commodities are provided to adolescents in the community
by selected community members, outreach workers and adolescents themselves
18. Do you provide any type of health services to adolescents in the community? 1 Yes 2 No
19. If yes, could you describe what you or your health facility staff do?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
20. Are adolescents involved in any of these activities? 1 Yes 2 No
21. If so, could you describe what they are?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
22. If no, why are they not involved?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
23. If you do not provide any type of health services to adolescent in the community could you give
reasons?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
24. Are there any other health facilities that provide adolescent health services in the community?
1 yes 2 no
25. If so, could mention them?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
82
Policies and procedures are in place that guarantee client confidentiality
26. Are there any policies and procedures that guarantee the confidentiality of clients in this health
facility? 1 Yes 2 No
27. If yes, could you describe what they are?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
28. How do you ensure that these policies and procedures are applied?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The point of health service delivers ensures privacy
29. Are there guidelines in place to provide privacy for adolescent clients? 1 yes 2 No
The point of health service delivery provides information and education through a variety of channels
30. Are there informational and educational materials available for adolescents in the waiting
room?
31. If yes, could you tell me what is there?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Adolescents are actively involved in designing, assessing and providing health services
32. Do you give adolescents opportunities to suggest/recommend changes to make services more
responsive to adolescent clients?
33. If yes, could you describe these opportunities?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
83
34. If no, why?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
35. In addition to being consulted as clients, are adolescents currently involved in decision-making
about how health care services are delivered to adolescents?
36. If yes, how are they involved?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
37. If no, why are they not being consulted?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The required package of health care is provided to fulfil the needs of all adolescents either at the
point of health service delivery or through referral linkages
38. Are adolescent clients offered the following reproductive health services?
Please put P for not provided R for referral and N for not offered
a. Information and counselling on reproductive health, sexuality and safe sex
b. Testing and counselling services for HIV
c. STI/RTI diagnosis
d. Pregnancy diagnosis
e. Treatment for STIs/RTIs
f. Care during pregnancy
g. Care during childbirth
h. Care after childbirth
i. Post abortion services
j. Information and counselling on contraception, including emergency contraception
k. Information and counselling condoms
l. Care and support for HIV-positive adolescents
m. Care and support for adolescent clients who have been physically or sexually assaulted
84
n. Treatment of such victims is followed by regular follow ups to maximise cure
39. If some services are not available, do your staff know how and where to refer clients for these
services? 1 Yes 2 No
Health-care providers have the required competencies to work with adolescents and to provide them
with the required health services
40. Do your staff have the knowledge and skills to provide the following services to adolescents?
a. Information and counselling on reproductive health, sexuality and safe sex
b. Testing and counselling services for HIV
c. STI/RTI diagnosis
d. Pregnancy diagnosis
e. Treatment for STIs/RTIs
f. Care during pregnancy
g. Care during childbirth
h. Care after childbirth
i. Post abortion services (where they are legal)
j. Information and counselling on contraception, including emergency contraception
k. Information and counselling on condoms
l. Care and support for HIV-positive adolescents
m. Care and support for adolescent clients who have been physically or sexually assaulted
n. Skills in following up adolescent clients who have been physically or sexually assaulted
Health-care providers use evidence-based protocols and guidelines to provide health services
41. Can you show protocols and guidelines at your health facility for:
a. Information and counselling on reproductive health, sexuality and safe sex
b. Testing and counselling services for HIV
c. STI/RTI diagnosis
d. Pregnancy diagnosis
e. Treatment for STIs/RTIs
f. Care during pregnancy
g. Care during childbirth
h. Care after childbirth
i. Abortion services (where they are legal)
j. Information and counselling on contraception, including emergency contraception
k. Information and counselling on condoms d
l. Care and support for HIV-positive adolescents d
m. Care and support for adolescent clients who have been physically or sexually assaulted
85
The point of health service delivery has the required equipment, supplies, and basic services
necessary to deliver the required health services
42. Does the health facility have a system for maintaining an inventory and recording the amount of
medicines and supplies in stock? 1 Yes 2 No
43. In the last six months, have you had shortages or stock-outs of medicines and supplies that
disrupted the provision of any health services offered?
44. If yes, please list the medicines and supplies.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
45. In the last six months, has unavailability of equipment or non-functioning equipment disrupted
the provision of any health services offered? 1 Yes 2 No
46. If yes, please list this equipment
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Capacity needs of adolescents’ health service Facility Managers
47. When you were at college/university adolescents’ health needs were part of your curriculum?
1 yes 2 no
48. If so, what were the main issues?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________
49. Have you had any in-service training on issues of adolescent health needs?
50. If so, what were the main issues?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
51. If no, would you like to participate in such training and what should be the curriculum of such
training?
86
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
87
Appendix C
Interview Guide for Health-Care Provider
Demographics
1. Name of Facility __________________________________________
2. Name of District: 1 Botha-Bothe 2 Leribe 3 Berea 4 Maseru 5 Mafeteng 6 Qachasnek
3. Location: 1 Urban 2 Rural
4. Geographical location: 1 lowland 2 Foothill 3 Mountain
5.
6.
7.
8.
Gender 1 female 2 male
Age ____________________________
How many year have worked in this facility ______________________
What are your areas of responsibility in this facility?
_____________________________________________________________________________________
______________________________________________________________________________
9. Circle the type of provider:
doctor nurse nursing assistant midwife other ____________
Adolescent-friendly health service characteristics:
Policies and procedures are in place that do not restrict the provision of health services on any terms
10. In your opinion what is an adolescent?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
11. Are there certain policies or procedures at this facility that might restrict the provision of health
services to some groups of adolescents, such as those who are less than a certain age; those
who are not married; or those who belong to a certain group?
12. If so, could you describe what these policies are?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
88
13. Can you describe the characteristics of some adolescents who may be denied services?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Health care providers treat all adolescent clients with equal care and respect, regardless of status
14. Are there some groups of adolescents who you do not feel comfortable in providing them with
services ( e.g. those less than a certain age, those who are unmarried, gays, lesbian bisexual)?
15. If so, could you explain why you feel uncomfortable?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________
Community members understand the benefits that adolescents will gain by obtaining the health
services they need, and support their provision
16. Do you think community members support the provision of reproductive health services to
adolescents? 1 Yes 2 No
17. If yes. Do they assist you in any way? Explain
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________
18. What service do you give to adolescent in the community?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
89
Policies and Procedures are in place that guarantee client confidentiality
19. Are there any policies or procedures in place that guarantee the confidentiality of adolescent
clients in this health facility? 1 Yes 2 No
20. If yes, what specifically do they say?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________
21. Are there any circumstances in which you would not follow any of these policies or procedures?
1 Yes 2 No
22. If yes, could you barriers that prevented you?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The Point of health service delivery ensures privacy
23. Are you ever interrupted by other staff when providing services to adolescent clients? 1 Yes 2
No
24. Is it possible for other people to hear your conversations or counselling sessions with
adolescent clients? 1 Yes 2 No
The Point of health service delivery ensures consultations occur in a short waiting time, and
(where necessary) swift referral
25. Do you know the procedures for making referrals for adolescent clients? 1 Yes 2 No
26. If yes, could you describe them to me?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________
27. Are adolescent clients provided with any assistance with the referral? 1 Yes 2 No
28. If yes, could you describe them?
_____________________________________________________________________________________
_____________________________________________________________________________________
90
_____________________________________________________________________________________
__________________________________________________________________________________
The required package of health care is provided to fulfil the needs of all adolescents either at the
point of health service delivery or through referral linkages
29. Are adolescent clients offered the following reproductive health services?
Put a P for provide R for referral N for not offered
a. Information and counselling on reproductive health services?
b. Testing and counselling services for HIV
c. STI/RTI diagnosis
d. Pregnancy diagnosis
e. Treatment for STIs/RTIs
f. Care during pregnancy
g. Care during childbirth
h. Care after childbirth
i. Post abortion services (where they are legal)
j. Information and counselling on contraception, including emergency contraception
k. Information and counselling on condoms
l. Care and support to HIV-positive adolescents
m. Care and support to adolescent clients who have been physically or sexually assaulted
n. Follow up treatment for adolescent clients who have been physically assaulted
30. If some services are not available at your health facility, do you know how and where to refer
clients for these services? 1 Yes 2 No
Health-Care providers have the required competencies to work with adolescents and to provide
them with the required health services
31. Do you believe that you have adequate knowledge and skills to provide health services to
adolescent clients in the following areas?
a. Information and counselling on reproductive health, sexuality and safe sex
b. Testing and counselling services for HIV
c. STI/RTI diagnosis
d. Pregnancy diagnosis
e. Treatment for STIs/RTIs
f. Care during pregnancy
g. Care during childbirth
h. Care after childbirth
i. Post abortion services (where they are legal)
j. Information and counselling on contraception, including emergency contraception
k. Information and counselling on condoms
91
l. Care and support to HIV-positive adolescents
m. Care and support to adolescent clients who have been physically or sexually assaulted
n. Treatment and follow up of adolescent who have been physically or sexually assaulted
32. Do you believe that you are able/trained to communicate with adolescents about the risks,
benefits and potential complications of the treatments and procedures you provide? 1 Yes 2
No
33. If yes, briefly what do you tell them?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
34. If no, state your training needs?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
35. Do you tell adolescent clients about alternatives to such procedures/treatments? 1 Yes 2 No
Health-Care providers use evidence-based protocols and guidelines to provide health services
36. Please show protocols and guidelines at your health facility for the following health services:
a. Information and counselling on reproductive health, sexuality and safe sex
b. Testing and counselling services for HIV
c. STI/RTI diagnosis
d. Pregnancy diagnosis
e. Treatment for STIs/RTIs
f. Care during pregnancy
g. Care during childbirth
h. Care after childbirth
i. Post abortion services
j. Information and counselling on contraception, including emergency contraception
k. Information and counselling on condoms
l. Care and support to HIV-positive adolescents
m. Care and support to adolescent clients who have been physically or sexually assaulted
n. Treatment and follow up to adolescent clients who have been physically or sexually
assaulted
92
Health-care providers are able to dedicate sufficient time to work effectively with their adolescent
clients
37. In your opinion, do you think you have enough time for your consultations with your adolescent
clients?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________
38. Do you sometimes have to see your clients quickly because there are many clients waiting to
see you? 1 Yes 2 No
The point of health service delivery has the required equipment, supplies, and basic services
necessary to deliver the required health services
39. Do you have all the medicines and supplies you need to manage your patients? 1 yes 2 no
40. In the last six months, have you had shortages or stock-outs of medicines supplies that disrupted
the provision of any health services offered? 1 Yes 2 No
41. If yes, please list the medicines and supplies.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
42. Do you have all the equipment you need to manage your patients? 1 Yes 2 No
43. In the last six months, has unavailability of equipment or non-functioning equipment disrupted
the provision of any health services offered? 1 Yes No
44. If yes, please list this equipment.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________
45. Do you receive supervision for the health service that you provide to adolescent? 1 yes 2 no
46. If yes, what is the type of supervision?
93
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Capacity needs of adolescents’ health service providers
47. When you were at college/university adolescents’ health needs were part of your curriculum?
1 yes 2 no
48. If so, what were the main issues?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________
49. Have you had any in-service training on issues of adolescent health needs?
50. If so, what were the main issues?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
51. If no, would you like to participate in such training and what should be the curriculum of such
training?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________
94
Appendix D
Interview Guide for support Staff
Demographics:
1.
2.
3.
4.
5.
Name of Facility _________________________________________
Name of District: 1. Botha Bothe 2 Leribe 3 Berea 4 Maseru 5 Mafeteng 6 Qachasnek
Geographical location 1 lowland 2 foothill 3 mountain
Gender: 1 Male 2 Female
How many years have you worked for this facility? _______________
Adolescent-friendly health service characteristic:
Some health services and health-related commodities are provided to adolescents in the
community by selected community members, outreach workers and adolescents themselves
6. Do you provide any type of health services to adolescents in the community? 1 Yes 2 No
7. If yes, could you describe what you do?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
8. Are adolescents involved in providing any type of health service to adolescents in the
community? 1 Yes 2 No
9. If yes, could you describe what they do ?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
10. What do you perceive as major health needs of adolescents in this community?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
11. What form of training do you need in order to enhance provision of health services to
adolescents?
95
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. Are there any specific or additional health services that you would like to provide to
adolescents?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
13. Are there cases of adolescents needs in the community that you refer to health facility? 1 yes 2
no
14. If so, what are they?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
15. Are adolescents involved in providing any type of health service to adolescents in the
community? 1 Yes 2 No
16. If yes, could you describe what they do ?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
96
Appendix E
Parents Focus Group Discussion
Demographics:
1.
2.
3.
4.
5.
6.
7.
Name of Facility: ___________________________________________
Name of District: 1 Botha-Bothe 2 Leribe 3 Berea 4 Maseru 5 Mafeteng 6 Qachasnek
Geographical Location 1 lowland 2 Foothill 3 Mountain
Gender: 1 Male and 2 Female
Do you have any children? 1 Yes 2 No
If yes, how many children are adolescents ( aged between 10 and 19 years) ?
How many are boys and how many are girls __________________________
Adolescent-friendly health service characteristics:
Community members understand the benefits that ad9lescents will gain by obtaining the health
services they need, and support their provision
8.
9.
10.
11.
12.
13.
14.
15.
Do you think adolescents need reproductive health services? 1 yes 2 no
If no, why?
Do you believe that adolescents should be provided with reproductive health services? Explain
What are the reproductive health services that are available to adolescents at this health
facility?
Are there certain reproductive health services that adolescents should not receive at this health
facility?
What efforts has the health facility made to inform the community about the types of services
adolescents need at this health facility?
What efforts have been made to inform the community about other aspects of adolescent
health and development?
What efforts have been made to inform adolescent about aspects reproductive health?
97
Appendix F
Focus Group Discussion For Adolescents
The focus group discussions should be undertaken with a minimum of five adolescents and a maximum
of ten. It would be helpful if we could have a well balanced group in terms of gender. We should try as
much as possible to encourage discussions and record the consensus. Please do not allow dominating
characters to over shadow others.
1.
a.
b.
2.
a.
b.
3.
a.
b.
4.
5.
6.
a.
7.
8.
9.
10.
a.
b.
11.
12.
a.
13.
a.
Have you or your friends been denied health services at the health facility?
If so, could you tell me for what health service?
Do you know why you were denied the service?
Has a health-care provider at the facility treated you or your friends in a manner that made you
feel upset?
If so, could you say who did this?
What do you think made that person act in this way?
Has the receptionist or any other type of support staff treated you or your friends in a manner
that made you feel upset?
If so, could you say who did this?
What do think made that person act in this way?
Have you or your friends been denied health services at the health facility because you could
not pay the fee for the health services
Do you know what days and times the health facility is open?
Are the working days and working hours of the health facility convenient for you?
What days and times would be most convenient for you?
Do you know what reproductive health services are?
Could you tell me which reproductive health services are offered at this health facility?
Do you think your parents/guardians would be supportive of you coming to this facility for
reproductive health services
Are there health services that your parents/guardians might not want to provided to you
If so, which ones?
Why do you think your parents/guardians might not want them provided to you?
Do you think other adults in the community are supportive of adolescents coming to this health
facility for reproductive health services? Explain
Are you aware of any health services that are provided to adolescents in the community?
If so what are they?
Are you aware of any adolescents who are involved in providing health services to other
adolescents in the community?
If so, could you describe what they are doing
98
Appendix G
Interview Guide for Policy Makers
Governance and Policy
1. Which national policies have specific provisions that would contribute to adolescent health,
such as:

Sexuality education for all adolescents

Package (s) of adolescent health services to be delivered at each level of care; adolescentfriendly health services standards applied across levels of care

Access to condoms, contraceptives, emergency contraception for adolescents

Discouraging forced marriages (abduction, elopement)

Discouraging polygamy that affects adolescents

Circumcision of adolescents by non medical traditional institutions

Minimum age for marriage

Age of consent to access health services

Access to HIV Testing; prevention care and treatment
2. Health Workforce

Is adolescent health included in pre-service training of all categories of health workers?

Are there mechanisms for periodic dialogue and collaboration between health worker training
institutions/organizations and health organization(s) establishment providing health services to
adolescents?

Are there supervision requirements for health workforce in relation to adolescent health service
delivery?
3. Medicines and Supplies

What are the arrangements for ensuring the availability of condoms (and contraceptives)
outside of health facilities to adolescents?
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4. Information

What are the policies and procedures for the collection and analysis of health information by
age and sex to reflect adolescent health, including:

Routine data on service-utilization in clinics and hospitals (the use of antenatal care, the use of
skilled birth attendants, the use of birthing facilities, and of postnatal care services; the use of
STI and HIV care and treatment; contraceptive and condom provision; HIV testing and
counselling)

Mortality and disease surveillance

Are there periodic reports of adolescent health behaviours and status including:

Surveys on knowledge, attitudes and behaviours related to substance use; mental health;
violence

Age specific maternal mortality and morbidity, pregnancy/birth rates, by age; pregnancy-related
mortality and morbidity, STI/HIV by age

Age of initiation of sexual activity within and outside marriage, use of contraception, and levels
of non-consensual

Accidents and injuries
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