Bottlenecks and Solutions During Implementation of the DREAMS Program for Adolescent Girls and Young Women in Namibia

Program Model

The DREAMS program in Namibia used a safe space model for program and service delivery.²⁵ A safe space is a supportive, judgment-free, safe and private location, such as a school classroom, church meeting room, or community center, where AGYW can meet regularly as a group led by a trained peer (or near-peer) mentor.²⁶ Over 100 safe spaces were established throughout both regions, each with a peer mentor assigned to meet once or twice a week with 20–30 AGYW grouped by age: 9- to 14-year-olds, 15- to 19-year-olds, and 20- to 24-year-olds. All AGYW and program staff, including the peer mentor, traveled to the safe space. School-based safe spaces did not require as much travel for AGYW compared to other safe spaces (e.g., community centers, churches, and health centers). Since AGYW were in the safe spaces for 2–3 hours or more, a small meal and drink were provided.

Recruitment

Recruitment was organized by age group. Participants aged 9–14 years were recruited almost entirely from primary schools. Girls aged 15–19 years were recruited from secondary schools, house-to-house engagement, special events, and health facilities. Young women aged 20–24 were recruited from tertiary education settings, house-to-house engagement, special events, and health facilities. In addition to providing classroom space, teachers and school administrators were involved in helping communicate with parents, assisting AGYW who experienced violence, and providing insight into the HIV/GBV education curricula, as many teachers had taught the same content to students. Recruitment was driven by PEPFAR targets for DREAMS (approximately 16,000 AGYW enrolled each year), which aimed to reach “saturation” whereby 75% of vulnerable AGYW aged 9–24 years in a district or region complete an age-specific primary package of DREAMS interventions and need-based secondary interventions (Figure 2).²⁷

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FIGURE 2

Flowchart of DREAMS Enrollment Activities and Interventions for All AGYW, and Additional Interventions for Eligible AGYW Based on HIV/GBV Risk in Namibia

Abbreviations: AGYW, adolescent girls and young women; DREAMS, Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe; GBV, gender-based violence; PrEP, preexposure prophylaxis; SRH, sexual and reproductive health.

Enrollment

Enrollment procedures included consent, collection of basic demographic information, and an HIV/GBV risk and vulnerability assessment that was introduced 1 year into program implementation. All AGYW provided written consent before participation. Written parental consent was obtained from parents of AGYW aged 9–19 years regardless of setting (young women aged 18–19 in schools were asked for parental consent because of the Ministry of Education, Arts and Culture policies and the program decided to require the same for out-of-school AGYW to maintain program consistency). To reach the most vulnerable AGYW, and as required by PEPFAR, program staff administered an HIV/GBV risk and vulnerability assessment to each AGYW, with responses determining eligibility for secondary DREAMS interventions.

Services

Regardless of risk assessment results, all AGYW received basic HIV/GBV prevention education and health and social services (blue arrow in Figure 2) while eligible AGYW received secondary interventions based on need (tan arrow in Figure 2). When meeting at the safe spaces, AGYW received regular HIV/GBV prevention education sessions led by peer mentors and, on select days, GBV services (psychosocial interventions and postviolence care) and sexual and reproductive health (SRH) and HIV prevention services (i.e., HIV testing, preexposure prophylaxis [PrEP], family planning). These services were provided by DREAMS program social workers, lay counselors, and health care providers (certified HIV testers and registered nurses). The primary package of services varied by age group. Program teams could visit 2–3 safe spaces in a day, providing services to nearly 100 AGYW in a single day.

Staffing

To implement DREAMS, the program employed 105 full-time staff including program managers, nurses, HIV testers, lay counselors, social workers, drivers, monitoring and evaluation (M&E) staff, and over 200 part-time staff (i.e., peer mentors, peer mentor supervisors, and community recruiters). The total implementation cost of DREAMS in the 2 regions over 2 years was approximately $US3.2 million. I-TECH established a separate DREAMS office in each region where staff were organized by team: M&E, social services, and health services. Each regional office oversaw a large team of part-time staff who were entirely community-based. Each region had 2 vehicles.

Data Collection and M&E

A monitoring system was designed to capture data required for PEPFAR reporting and to support program quality and continuity of services. Data were collected at enrollment and at each point of service delivery and managed using Research Electronic Data Capture (REDCap).^28,29 Attendance by AGYW at health education sessions was collected on paper by peer mentors and entered in REDCap by M&E staff. M&E staff also administered both a baseline questionnaire and the HIV/GBV risk assessment questionnaire to all AGYW at enrollment. Data on layering were collected (i.e., the number of services each AGYW received) but are not reported here because the service definitions varied considerably during this 2-year start-up phase of DREAMS in Namibia.

Program Access Bottlenecks

Although gathering AGYW in safe spaces was logistically easier in school settings, it was challenging to screen and enroll hundreds of AGYW at the end of the school day, especially when AGYW had to walk long distances home before dark for their safety (Table 1). Gathering written parental consent forms in person from parents for AGYW aged 9–19 years was required because of government regulations and often took 2–3 weeks; AGYW whose parents could not be reached could not participate. Enrollment sessions also required extensive data collection, such as demographic information and risk/vulnerability screenings, which required substantial staffing, typically 10–15 staff per session. To ensure AGYW were not enrolled in more than 1 space, Internet connectivity was needed for M&E staff to check new enrollees against existing records using a table or laptop computer for access to this database. Lastly, to enable enrollment of 20- to 24-year-olds attending tertiary education institutions or technical training colleges, program leadership spent many months developing and formalizing partnerships (e.g., memoranda of understanding) allowing participation in DREAMS, which delayed recruitment of this age group (Table 1).

Program Access Solutions

Health Education Bottlenecks

Although there were Government of Namibia–approved curricula available for HIV/GBV prevention for 9- to 14-year-olds and 15- to 19-year-olds, neither curriculum had been updated for at least 5 years (Table 1). Updating these materials with current evidence-based HIV and GBV content required significant modifications. AGYW aged 15–19 years and their peer mentors reported that the didactic format of their curriculum was dull and unengaging, which may have contributed to low attendance. This was especially problematic in the Khomas region where attendance in and around Windhoek was already hampered by distance and safety concerns. No curriculum existed for AGYW aged 20–24 years and the considerable amount of time it took to identify an evidence-based curriculum for this age group that was acceptable to all stakeholders slowed implementation.

With thousands of AGYW at over 100 safe spaces, attendance tracking required for reporting purposes was an especially time- and labor-intensive process. It took up valuable time for all team members, especially peer mentors and M&E teams, and came at the expense of other M&E processes needed for improving program quality (Table 1).

Employment as a peer mentor was often the first formal employment experience for the young women hired into this role. Even though all peer mentors were fully trained to deliver the education sessions, their skill and competence varied widely, requiring considerable ongoing training, support, and supervision to maintain a high teaching standard and ensure ongoing attendance reporting (Table 1).

Health Education Solutions

Health Services Bottlenecks

Although PrEP was included in the Namibia 2016 National Guidelines for Antiretroviral Therapy, development of the Government’s PrEP implementation plan launched concurrently with the DREAMS program, leaving DREAMS without an existing national PrEP delivery plan to follow.³¹ As a result, many aspects of PrEP delivery, including training of health care workers and health communication activities such as flyer and poster development, became the responsibility of DREAMS (Table 1). Before DREAMS, PrEP services were delivered entirely within health facilities; however, AGYW reported that they preferred not to obtain PrEP at government facilities due to some health workers’ lack of discretion and unwelcoming attitudes.

DREAMS relied on the Namibian government’s commodities such as condoms, HIV test kits, family planning methods, and PrEP, which are distributed to public health facilities by the MOHSS Central Medical Stores. For various reasons, including a severe economic contraction in the country, these commodities were at times unavailable for long periods. Stock-outs not only delayed DREAMS health services but also complicated follow-up services for AGYW, especially family planning and PrEP. Other complications included the refusal of some schools early in the implementation of DREAMS to allow family planning services to be delivered in the school setting. While family planning service delivery in schools was under discussion between stakeholders, the program provided these services to AGYW in community settings only.

Health Services Solutions

Social Services Bottlenecks

The Ministry of Gender Equality, Poverty Eradication and Social Welfare, which is responsible for managing GBV cases in Namibia, was often too understaffed to manage the high number of cases identified through DREAMS (Table 1). While the social workers on staff were able to provide services to AGYW most in need, the caseload far surpassed existing staff capacity. In addition, Namibian health policy prohibits health facility clinicians from attending to rape cases unless adequately trained, therefore necessitating the management of these cases by GBV units at the referral hospital level. When DREAMS staff identified a rape case, they offered to transport the survivor to the hospital and help her register at the GBV unit. Support for rape cases included providing initial first-line trauma counseling and at times calling the GBV unit to confirm availability of the social worker, contacting the AGYW’s family (or friend), or contacting the police. As a result of its time-sensitive nature, support for rape victims took immediate precedence over other GBV counseling and case management activities for AGYW in DREAMS, often requiring considerable time and effort from the program social workers (Table 1).

Finally, the DREAMS program did not have enough private, confidential spaces to provide in-depth psychological counseling to many AGYW. This lack of privacy made it difficult for AGYW to discuss their GBV experiences with program staff. In such cases, the sessions were delayed until a private space could be identified (Table 1).

Social Services Solutions