Shahnaz lives in the Lavkushnagar slum in Uttar Pradesh with her husband Nasruddin. Tailoring is their livelihood, but it offers a meager and insecure income. Shahnaz is very familiar with hardship and has faced many challenges since childhood. 

"I lost my father when I was merely nine years old. My mother, due to low income, couldn't take care of seven children. Hence, as a result of social pressure, she arranged my marriage. I never went to school. I got married at the age of 12 and I conceived soon after my first menstrual period."

Shahnaz had her first child by the time she was 13. Since then, she has added two more children to her family and experienced four miscarriages. The pregnancies, births and miscarriages have taken a toll on Shahnaz's health.

Her husband Nasruddin assumed it was her responsibility to take care of things like family planning and, unfortunately, they never spoke about it. Soon, Shahnaz was pregnant again with twins. In the eighth month of pregnancy, she experienced heavy bleeding and was rushed to a hospital where both were stillborn. The hospital bills were more than she and Nasruddin could afford, so they had to borrow 10,000 rupees for her treatment. Life became tougher still for Shahnaz as she struggled to pay for food and medicine. By the time she turned 28, Shahnaz found the courage and determination to do something about family planning. She decided that the next time an Accredited Social Health Activist (ASHA) knocked on her door, she would not ignore her and miss the opportunity to find out about about family planning method choices. Ultimately, she met with a TCI-coached ASHA and decided to adopt female sterilization as her method of choice. Shahnaz is no longer stressed by the fear of becoming pregnant again.

"When I was child I had many dreams for the future. I wanted to earn [money] and become independent. But, due to early marriage, I could not fulfill my dreams. I don't want my daughters to make the same mistakes I have made in my life. We are educating our daughters so that they hold the power to create their ideal future."

"When I was child I had many dreams for the future. I wanted to earn [money] and become independent. But, due to early marriage, I could not fulfill my dreams. I don't want my daughters to make the same mistakes I have made in my life. We are educating our daughters so that they hold the power to create their ideal future."

Shahnaz is now learning how to read and write from her son. She is also saving some money for the future. Like Shahnaz, thousands of women in India wish to space or limit their family size but are either unaware of or do not have access to family planning choices.

This is why state and city governments in Indian states like Uttar Pradesh are strengthening the capacity of urban ASHAs, with TCIHC's support, to provide quality family planning counseling and referrals to meet the needs of women like Shahnaz.

To learn more about the impact of urban ASHAs and how to adopt or adapt this high-impact approach, check out Enabling Urban Accredited Social Health Activists.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-urban-tales-family-planning-offers-new-beginnings-for-young-mothers-in-india/You can read all previous stories also athttps://tciurbanhealth.org/topics/india-urban-tale/.

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visithttps://tciurbanhealth.org/india-toolkit/and https://tciurbanhealth.org/topics/india/.

The Challenge Initiative for Healthy Cities (TCIHC) in India worked strategically through its adolescent and youth sexual and  reproductive health (AYSRH) program to reach first-time parents with informed-choice counseling and modern contraceptive services over a six-month period ending June 2019 in five cities in Uttar Pradesh (Allahabad, Firozabad, Gorakhpur, Saharanpur and Varanasi). 

The first step was to make sure young first-time parents were visible, so they can receive appropriate services, including contraception, so TCIHC coached and mentored active urban Accredited Social Health Activists (ASHAs) to identify them from their urban health index registers (UHIR). This effort included coaching to make sure the ASHAs knew how to complete their UHIRs, develop lists of women based on age and parity (i.e., number of children), and devise a priority list of young first-time parents. At the same time, TCIHC worked to overcome provider bias to ensure providers and facility staff were aware of the latest medical guidelines and had accurate knowledge on all the methods available for young first time-parents at both the facility (medical-officer-in-charge and staff nurse) and community level (ASHA worker). "

Studies have shown that low parity can be a barrier to accessing some family planning methods. Data from the Urban Reproductive Health Initiative (URHI) found that 90% of the providers restricted access to female sterilization and intrauterine contraceptive device (IUCD) based on the number of children that a client has. Of this, 65% of doctors required a client to at least have one child and 63% of all traditional birth attendants believed that a woman can opt for an IUCD only if she had two children or more. As a result, a plan was devised to conduct whole site orientation (WSO) - a TCIHC proven approach - on adolescent-friendly services at urban primary health centers (UPHCs) in the five cities. Following this, the TCIHC team garnered support from city health teams to organize special fixed day static (FDS) services - another TCIHC proven approach - for first-time parents. These efforts significantly increased contraceptive uptake among first-time parents, aged 15-24, as illustrated in Figure 1. Forty-one percent of all women aged 15-24 accepting a family planning method at a UPHC were first-time parents, across the five TCI AYSRH cities, as compared with 28% in the 26 TCIHC-supported cities implementing TCI's proven family planning solutions in Uttar Pradesh, Madhya Pradesh and Odisha with no special focus on AYSRH.

Upon learning about the AYSRH impact, many of the TCI cities implementing family planning only informally began adding AYSRH activities. As a result, these cities also began to exhibit increased results in reaching women 15-24 years and referring them to FDS (Figure 2). While TCIHC AYSRH cities still reached more young women, ages 20-24, (50.3%) than TCI family planning only cities (42%), the fact that there is not a large gap between the two different city groups speaks to the scalability of the AYSRH approaches.

For reading this story on TCI University please https://tciurbanhealth.org/reaching-first-time-parents-in-the-tcihc-supported-youth-friendly-cities-of-uttar-pradesh/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

The Challenge Initiative for Healthy Cities (TCIHC) in Uttar Pradesh, India, aims to increase access to sexual and reproductive  health (SRH) information and services for adolescents and youth in urban environments. TCIHC is partnering with the Government of India's national adolescent health program called Rashtriya Kishor Swasthya Karyakram (RKSK) to offer adolescent-friendly health services (AFHS) at urban primary health centers (UPHC) for the urban poor. 

Because UPHCs are nested within complex social and cultural settings, health service providers working at UPHCs maintain their own beliefs and value system. Healthcare systems can also influence provider actions in the form of policies and norms. These influences may induce provider biases, leading to a lower quality of care, especially for unmarried adolescents.

To address this, TCIHC coached RKSK to launch its high-impact whole site orientation (WSO) best practice to orient all staff in an UPHC on the SRH needs of adolescents and youth. The WSO also addresses any biased attitudes and beliefs towards youth SRH issues that staff may hold that could unintentionally cause harm. Working within the health system, TCIHC in collaboration with RKSK coached the Medical Officers In-Charge (MOICs) of the UPHCs to conduct WSO without TCIHC or RKSK support for all facility staff to create a more enabling environment for adolescents that also ensures quality adolescent-friendly health services.

In Aligarh, Dr. Arshiya Sherwani, MOIC of UPHC Nagla Tikona, has facilitated WSO with her staff. In the interview below, she shares with TCIHC her experience and reflections on the changes she has observed after WSO.

Discovering my own biases

In December 2020, TCIHC virtually coached me on the goal and objective of orienting all UPHC staff though a WSO. The coaching I received was in fact a behavior change intervention aimed at reducing my own bias. Unsurprisingly, I discovered that social norms were driving my biases. The most pervasive social norm was the significance of sexual abstinence before marriage. And, therefore, my attitude and belief was that contraceptives were meant for married couples only. I recognized that my attitude towards the provision of contraceptives is shaped primarily by client's age, parity and marital status. I realized youth must pass through many barriers to access SRH. Provider bias is one of the gates. TCIHC provided orientation material based on RKSK guidelines. I received 'how-to-guidance' on conducting a values clarification exercise through a whole site orientation for all staff.

After equipping myself, in January 2021, I conducted WSO sessions for my entire UPHC staff at the facility irrespective of cadre and technical skills, which included staff nurse, lab technician, pharmacist, Auxiliary Nurse Midwives (ANM), Accredited Social Health Activists (ASHA), support staff etc. With support from TCIHC, I attended a youth-led City Consultation Workshop (CCW) in Aligarh organized by RKSK. Here I had heard adolescents and youth candidly share their opinions and desires on SRH issues. I was a bit shocked but I immediately realized the necessity of SRH care for unmarried adolescents and youth. TCIHC initiatives - the AYSRH CCW and WSO - both changed my mindset about the importance of providing SRH information and services to adolescents and youth."

Facilitating a whole-site orientation

Facilitating the WSO session was a learning experience for me. The design of activities, such as role plays and cases studies, enabled my staff to overcome non-technical biases rooted in attitudes and beliefs, without explicitly saying that they are doing this. An interesting attitude that emerged was that of staff engaging with young clients from parental perspective. The belief that we are in a better, more informed position to make decisions for clients. I encouraged WSO participants to raise concern without hesitation. This created a non-threatening environment for them to ask and clarify their indecisions. I addressed their questions related to menstruation, puberty and physical changes associated with adolescence. While it was difficult, I was determined to discuss contraceptive needs and behaviors of unmarried adolescents and teenagers and invested time in discussing this topic.

The session on values clarification challenged staff to explore the reasons behind their beliefs, and also reflect on the consequences of their actions when clients are denied contraceptive methods. I tried role plays with the help of the game 'Bhranti aur Kranti' (Myth and Revolution) from RKSK's Peer Educator Training Manual. ASHAs enacted the role of Bhranti who asked questions and Kranti who responded with correct answers with rationale. This game helped in busting myths about SRH needs of adolescents - married or unmarried. Apart from this, I also coached the facility staff on the competencies required for delivering SRH services in a friendly manner, like being non-judgmental, maintaining confidentiality and privacy, building trust, interpersonal skills, etc. I covered topics of nutrition, non-communicable diseases, substance misuse, violence and mental health. This orientation aided staff to recognize and address their unconscious biases related to SRH needs of adolescents, which were mainly associated with gender, marital status and age. I was motivated to see the City Community Process Manager from the National Health Urban Mission (NUHM) participate in the WSO. Meanwhile, through the session, I endeavored to sensitize the staff towards SRH needs of adolescent and covered standards set by RKSK for AFHC [adolescent-friendly health clinic]."

After coaching

After the WSO, I witnessed an explicit change in the attitude of UPHC staff. I observed them being mindful of adolescent needs and being empathetic when counseling them during facility Adolescent Health Days (F-AHDs). WSO had truly prepared the staff. After this, with TCIHC's technical coaching on F-AHD and detailed coaching on how to organize it, we started F-AHDs on the fifth of every month. With management coaching of TCIHC, we arranged reporting formats, sanitary napkins and medicines for adolescents from the Nodal Officer for F-AHDs. We also established a counseling corner for adolescents to maintain confidentiality and privacy. My team of staff nurses and ANMs along with TCIHC-coached ASHAs and Anganwadi worker publicize F-AHDs and encourage adolescents to use the services. These community health workers motivate adolescents from urban health nutrition day and slum areas. Through F-AHD, we promote health-seeking behaviors among adolescent boys and girls and provide services like hemoglobin testing, body mass index screening and provide iron folic acid supplements (WIFS) and albendazole capsules, as required. Additionally, counseling services are offered to each visiting adolescent where they are counseled about nutritious and balanced diet, mental health issues, genital and menstrual hygiene, among other issues.

As a result of all of these efforts, the community is now well-aware about adolescent health services availability in our facility and adolescents are regularly visiting the facility and obtaining services. They comfortably talk to us without hesitation and discuss body changes, menstruation, etc. My staff now ensures that no adolescent goes home without availing services. Whenever my staff have any doubts I discuss with them individually and also refresh their knowledge in UPHC level group meetings. At times, we face challenge when adolescents visit the facility without guardian and share about sexual abuse incidences during counseling sessions. We have to refer such cases to the RKSK counsellor at the District Hospital because these are legal issues. In addition, when we have high footfall on F-AHDs, maintaining privacy during counseling session becomes a big challenge. UPHCs will benefit by having dedicated trained counsellor for adolescents, which is currently not in place.

Till date, we have conducted three F-AHDs and provided services to 116 boys and girls. Often RKSK and NUHM officials visit F-AHD and the UPHC and coach us on management of AY and FP services. I also continuously assess the progress of health services uptake, especially AY and FP during the monthly UPHC meeting and address issues and challenges by coaching the staff and discuss plans to improve the services. I can proudly say that in my UPHC, adolescent health services are prioritized and provided in a manner that respects the rights of adolescents, their privacy and confidentiality. Moving forward, to build an enabling environment and for sustainable change, parents, teachers and the community need to be sensitive so that adolescents can seek and utilize SRH services without any hesitation."

Working with 10 more cities across Uttar Pradesh, TCIHC has created 140 such master coaches who have conducted 231 WSOs. Having met this first criteria for AFHC, TCIHC is coaching AY city teams to regularly host F-AHDs and upload data from F-AHDs onto HMIS. In addition, TCIHC is advocating at the state level to get AYSRH counselors placed at UPHCs and, thus, support RKSK's vision of making each UPHC an adolescent-friendly health clinic.

For reading this story on TCI University please https://tciurbanhealth.org/addressing-provider-bias-through-whole-site-orientation-in-uttar-pradesh-india/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

"As a child, I was enamored by the doctor's profession. A mere sight of someone dressed in a white coat brought respect in everyone's eyes. I wanted to be a doctor too! Growing up in a low-middle class family and the financial constraints [we faced] allowed me to only pursue a General Nursing and Midwifery diploma course from Tundla, Uttar Pradesh (UP). I stay in Tundla and travel 70 kms to and from my home to the UPHC in Firozabad. It is far, but I enjoy my work." 

Manisha is a committed staff nurse posted at the Sant Nagar urban primary health center (UPHC) in Firozabad. She supports all government health programs implemented at the UPHC, including family planning. As a result of advocacy efforts by The Challenge Initiative (TCI), she was trained on family planning counseling and how to provide the injectable Antara and insert intrauterine contraceptive devices (IUCDs). Manisha shared how she actively followed up with her family planning clients during the COVID lockdown and her absence from the UPHC: "My mother is a cancer patient. And during the COVID lockdown, she was hospitalized. At that time, I stayed with her at the cancer hospital. I carried my family planning client's register to remind Antara clients about their next due dose. I used to telephonically counsel family planning clients who visited the UPHC. I am happy that in my absence none of the family planning client were returned without availing services"

She also stressed the important role society - in particular the family - plays in supporting or obstructing the uptake of family planning services. She recalled a common situation she often faces:

"While working as a staff nurse, I found that reluctance from the husbands and in-laws are the biggest obstacles preventing a woman from availing family planning services. I remember an incident when a frail woman visited our UPHC to take STI (sexually transmitted disease) treatment. She had seven children. I counseled her on family planning but her husband staunchly refused it. Later, the woman kept on visiting the UPHC for medicines. I was dismayed to see her suffer. Once her husband had accompanied her, I grabbed courage and spoke to him in detail about the poor condition of his wife's health. I explained the benefits of family planning. After a number of counseling sessions, I was able to persuade him to use one of the methods. I felt a sense of relief and satisfaction."

This story highlights the importance of two of TCI India's high-impact approaches - Strengthening Provider Capacity and Male Engagement.

For reading this story on TCI University please visit: https://tciurbanhealth.org/tci-india-urban-tales-firozabad-staff-nurse-finds-satisfaction-in-serving-others/. You can read all previous stories also at https://tciurbanhealth.org/topics/india-urban-tale/.

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

The graph on the next page shows comparative HMIS data of family planning clients served at UPHCs from March 2018 to March 2019. Average family planning uptake per month also increased in UPHCs by 66% when compared to the previous year. These results were due to TCIHC's use of near-time, real-time data for decision-making to inform all programming - a long-held TCIHC guiding principle.

TCIHC analyses data from HMIS every month to identify success levers and challenges. In January 2019, analysis of HMIS and project data indicated that cities were falling behind previously set goals on meeting the estimated demand for family planning for the year.

With the GOI's fiscal year ending at the end of March, TCIHC introduced the Mission March concept as a concerted effort to accelerate city performance related to family planning. The word 'mission' was meant to indicate that work was required in a mission mode where each effort was focused and coordinated to improve the city's family planning demand.

TCIHC city team presented its comprehensive Mission March roadmap at divisional and monthly family planning review meetings and sought government buy-in. The GOI directed Nodal Officers of its National Urban Health Mission (NUHM) to support the drive. Then, TCIHC-supported Urban Nodal Officers and Coordinators reviewed eligible couples data from the family planning due-list kept by every Accredited Social Health Activist (ASHA). Next, the team utilized the ASHA monthly meeting platform to orient ASHAs on what was expected leading up to the Mission March. TCIHC emphasized streamlining the due-list of eligible family planning clients from the Urban Health Index Registers (UHIRs), making sure all interested clients were routed to service delivery points of their choice.

Thus, those requiring secondary family planning services were directed to district hospitals and medical colleges, and those seeking pills, condoms, injectables and IUCDs were directed to UPHCs. At the same time, the team coached the ASHAs on providing correct family planning information to clients and mobilizing the community on the fixed-day static (FDS) service day, which is also referred to as family planning day (FPD).

"During Mission March, all ASHAs, ANMs and AWWs worked as team to reach out to more men and women with family planning messages. Getting more family planning clients was our prime mission. TCIHC team and medical officers of UPHCs guided us on how to improve our efficiencies. Now, family planning is a part of my daily counseling." - Kusum Lata Kashyap Urban ASHA Lucknow, Uttar Pradesh

The Anganwadi workers (AWW) of Integrated Child Development Services were also engaged to refer family planning clients from slums to service delivery points on FDS/FPD. The team also worked with Auxiliary Nurse Midwives (ANMs), who referred family planning clients from Urban Health Nutrition Days (UHND) and routine immunization sessions.

In addition, UPHC medical officers were entrusted to track the ASHAs' monthly plans to ensure maximum coverage, meeting the contraceptive needs of non-users on the ASHAs due-list. A formal WhatsApp Group was created by Nodal Urban Health Officer and Urban Coordinator of each city to track and review UPHC data daily and mitigate any challenges faced by any particular UPHC. TCIHC team ensured that this WhatsApp Group was regularly updated with FDS/FPD data. To manage any human resource gaps that may arise during this period on the FDS/FPD day at any UPHC, all trained staff were informed by the medical officers about the Mission March and were requested to support family planning services during FDS/FPD in nearby UPHCs wherever required.

At the same time, TCIHC supported the UPHC team to arrange two months of supplies of family planning commodities to meet higher demand. Condoms and oral contraceptive pills were made available to ASHAs so they could readily provide family planning services during daily household visits and monthly outreach camps conducted by UPHCs. Most significantly, TCIHC worked with the city government to strengthen data and reporting during this month in particular.

Mission March not only helped men and women access and obtain their family planning method of choice, but also created a sense of ownership among the government, UPHC staff and community health workers for family planning services. GOI officials noted IUCD uptake data from March 2019 was 282.69% higher than March 2018. In fact, 64.5% of overall IUCD acceptors from January to March 2019 came from March 2019. Mission March successfully demonstrated that if all units worked together towards a common goal, more and more family planning clients can be served.

"Mission March successfully demonstrated that if all units worked together towards a common mission, more and more family planning clients can be served. Each month, family planning clients are increasing and we intend to maintain this pace.." - Dr. A.K. Singh Additional Chief Medical Officer and Nodal NUHM Kanpur, Uttar Pradesh.

For reading this story on TCI University please visit: https://tciurbanhealth.org/project/a-mission-march-in-india-leads-to-311-increase-in-annual-client-volume-at-tcihc-supported-facilities/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.