An exploration of barriers and enabling factors for young people with disabilities to access sexual and reproductive health services in Senegal Eva Burke, Alex le May, Fatou Kébé, Ilse Flink

Study overview  The ASK programme – Access, Services, Knowledge – to enhance the uptake of SRH services among young people aged between years through information and education; youth-targeted and youth-friendly services; and raising awareness and acceptance of young people’s sexuality.  Operates in 7 countries; was introduced in Senegal in  Rutgers is the lead of the Alliance  Funded by the Dutch Ministry of Foreign Affairs

Study objectives The overall objective: to identify barriers and enablers to sexual and reproductive health (SRH) services among young people with disabilities (YPWD) in Senegal. The following sub-objectives were explored:  To document the knowledge of and attitudes to SRH services by YPWD;  To document current challenges YPWD face to access SRH services;  To identify which SRH services YPWD want and where they want to access them;  To document barriers and opportunities for access to SRH information and services through the private sector.

Senegalese context

Population: 14 mn 33% aged years 46% below national poverty line 5.9% living with a disability (~ ) Low education / income CPR: 16% / 5.8% adolescents 1 in 3 married by 18 years 1 in 5 childbearing by age 17; 32% by age 18 Conservative attitudes to sex Predominantly public sector- fees for services Barriers for young people: Affordability Provider attitudes Lack of trust Political commitments to uphold rights: 1.CRPD ratified in Loi d’Orientation Social> health cards (cartes d'égalité des chances) 3.Young people recognised in national SRH plans

Methodology

Study participants: Study population  Young people aged 18 – 24 years  Living with a physical or sensory (visual or hearing) impairment  Sites: Dakar, Thies, Kaolack Data collectors  Peer approach: YPWD as data collectors  Trained using the EXPLORE toolkit, developed by Rutgers and IPPF, to enhance youth participatory research techniques

Methodology: qualitative (FGDs and IDIs) 8 male FGDs 2 mixed FGDs 7 female FGDs 23 male respondents 27 female respondents

Methodology

Results

Results: sexual activity & experience Most in relationships, with nearly half of interview respondents reported having had sex (three fold more men than women) Onset of sexual activity often linked to marriage “I live with a disability but this is not an obstacle to having sexual relations and bearing children” (female, 25, hearing impairment)

Results: gender norms  Marriage an important factor for women for onset of sexual activity  Judgemental attitudes towards women who have sex before marriage  Male and female respondents report female family members as confidants for issues related to SRH (absence of male members) “For me, no single girl has the right to have sexual relations. It should be done only after marriage” (female, 19, visual impairment)

Results: sexual violence  Experience of rape was common amongst women with hearing impairments  All rape incidences took place when the women were adolescents or younger, and perpetrators were often family members or family friends, and in one case a worker in a professional facility.  Only one reported seeking medical help following the rape (female with physical disability) I have never been in love. I was raped in 2008 by my uncle’s friend. Since then I have been distrustful…I have never had sexual relations apart from the rape…I am scared that I will be raped again. That’s the reason I don’t dare have a boyfriend” (female, 22, physical impairment)

Results: contraception knowledge and use  1/3 of sexually active respondents reported never use of a contraceptive method  Wide knowledge of condoms but low knowledge of range of other contraceptive methods, more pronounced amongst young people with hearing impairments  Negative perceptions of contraceptive use by unmarried / married women

Results: sources of information  Friends, followed by (female) family members, are the most important confidants for advice regarding relationships  « Non-confidants » are namely one or both parents due to fear, taboo or embarrassment to talk to them regarding issues related to SRH  Most cited no other sources of information “In my family, we never talk about questions related to sexuality” (female, 20, hearing impairment) “The main problem remains the lack of information regarding the existence of such structures” (male, 24, visual impairment)

Results: support networks  Participants across all disability groups and sexes demonstrated a need to be accompanied by a family member or friend to access health services  Dependency on family members for young people with hearing impairments due to communication barriers The fact of not being able to communicate with others causes us enormous problems. I am obliged to be accompanied by my mother” (male, 24, hearing impairment)

Results: access to SRH services  Majority reported never use of a SRH service  Only 9 respondents had accessed a SRH service (public health centres, NGOs, pharmacies, CHWs)  Perception of better quality services in the private sector and more confidential, but perceived as more costly  3 key determinants for choosing a SRH service: confidentiality anonymity proximity

Results: barriers to SRH services Financial Provider attitudes / discrimination due to their disability Parents’ attitudes Accessibility – physical and communication NGO/private sector willingness to provide subsidised or free services to YPWD but absence of specific strategies

Study limitations  < 18 years not part of the study  Geographic limitations  Exclusion of other disabilities and disorders  Response bias  Data collectors’ capacity  Limited health sector analysis

Conclusions YPWD face a double burden in accessing SRH services; women a triple burden Youth Affordability Provider attitudes Access to information and services Disability Affordability Provider attitudes and capacity (disability) Access (physical, communication) Disability-friendly info Gender Conservative social norms Preserving virginity until marriage Contraceptive use within marriage

Concluding recommendations 1.Increase access to youth and disability appropriate information and services:  Evidence base of needs of YPWD  Appropriate format (braille, audio etc.)  Capacity building of service providers  Involving support networks  Peer approaches  Structural changes to enabling physical accessibility  Strengthen referral mechanisms 2.Urgent need to assess scale of sexual violence and ensure support mechanisms in place to respond accordingly:  Data needed on sexual violence  Increase access to information/support (including facilitating communication)  Strengthen referral mechanisms (psychosocial, legal, clinical)  Capacity building of service providers

Concluding recommendations 3.Remove financial barriers to SRH services:  Free or subsidised public services for young people / YPWD  Ensure health cards include free access to SRH services for YPWD  Explore public-private partnerships and initiatives to increase access to quality services 4.Increase data and research on people with disabilities to inform policy change and interventions  Disaggregation of national and local level data by disability and by age group  Further research needed on sexual violence, frequency of contraceptive use, reasons for non use of contraceptives etc.

Thank you Full report available in English and French (also shortly available on Rutgers website )