Adolescent & Youth-Friendly Services

© 2015 Arturo Sanabria, Courtesy of Photoshare

Adolescents and youth face a wide range of barriers in accessing high-quality sexual and reproductive health (SRH) services. These include:

  • Structural barriers, such as laws and policies requiring parental or partner consent, distance from facilities, costs of services and/or transportation, long wait times for services, inconvenient hours, lack of necessary commodities at health facilities, and lack of privacy and confidentiality.
  • Sociocultural barriers, such as restrictive norms and stigma around adolescent and youth sexuality; inequitable or harmful gender norms; and discrimination and judgment of adolescents by communities, families, partners, and providers.
  • Individual barriers, such as young people’s limited or incorrect knowledge of SRH, including myths and misconceptions around contraception; limited self-efficacy and individual agency; limited ability to navigate internalized social and gender norms; and limited information about what SRH services are available and where to seek services.

Although adolescents and youth are a heterogeneous group, they share two common characteristics in seeking health services: They want to be treated with respect and to be sure that their confidentiality is protected (WHO, 2002).

Adolescent and youth-friendly services (AYFS) (also called youth-friendly services, YFS) are designed to address these barriers in order to attract and retain young people for services (Senderowitz, 1999). In addition, there is growing recognition of the need to make existing health services youth-friendly instead of having stand-alone or separate-space models for delivery contraceptive services to adolescents and youth (USAID, 2015).

In collaboration with partner organizations and national stakeholders, World Health Organization (WHO) developed the following Global standards to improve quality of health-care services for adolescents.

  • Standard 1: Adolescents’ health literacy
  • Standard 2: Community support
  • Standard 3: Appropriate package of services
  • Standard 4: Providers’ competencies
  • Standard 5: Facility characteristics
  • Standard 6: Equity and non-discrimination
  • Standard 7: Data and quality improvement
  • Standard 8: Adolescents’ participation

These standards help to minimize variability and ensure a minimal required level of quality to protect adolescents’ rights in health care (Nair et al., 2015). The TCI AYSRH toolkit includes interventions or approaches that address each of these standards. As a result, this approach page focuses primarily on guidance for training providers, making facility improvements to better attract and serve adolescents and youth, and facility-level data considerations and requirements.

What Are the Benefits?

  • Facilitates young people’s access to and satisfaction with services
  • Gives higher quality SRH services to young people
  • Empowers health providers to be advocates for young people
  • Encourages future health-seeking behavior among young people

How to Implement?

These steps are informed by USAID’s High Impact Practice brief on Adolescent-friendly contraceptive services: mainstreaming adolescent-friendly elements into existing contraceptive services.

Ensure institutional standards for youth-friendly service align with international standards
Most health ministries and service-providing institutions have articulated the core competencies that health providers need in order to provide youth-friendly SRH services, and included them policies, strategies and/or national standards. These important reference documents ensure awareness and standardization across programs, service delivery points, and providers.

Example: Ministry of Health, Kenya
The National Adolescent Sexual and Reproductive Health Policy (2015) articulates the following priority actions related to enhancing the skills of health professionals:

  • Build the capacity of health providers to provide SRH information to adolescents;
  • Enhance capacity of law enforcers and health service providers on prevention, response and mitigation of sexual gender-based violence (SGBV);
  • Build capacity of health providers to provide adolescent-friendly SRH services through in service, on job training, mentorship and continuous medical education;
  • Support integration of ASRH training into pre-service curriculum in all medical training institutions;
  • Strengthen quality assurance mechanisms through continuous support supervision and mentorship at all levels to provide adolescent-friendly SRH services;
  • Building capacity of program managers, planners and service providers on data utilization for decision-making.

If such standards do not exist and must be developed, young people or youth organizations are crucial allies in ensuring that they are youth-responsive and context-specific. The World Health Organization (WHO)’s Core Competencies in Adolescent Health and Development for Primary Care Providers includes:

Domains Competencies
Basic concepts in adolescent health and development, and effective communication
  • Competency 1.1. Demonstrate an understanding of normal adolescent development, its impact on health and its implications for health care and health promotion
  • Competency 1.2. Effectively interact with an adolescent client
Laws, policies and quality standards
  • Competency 2.1. Apply in clinical practice the laws and policies that affect adolescent health-care provision
  • Competency 2.2. Deliver services for adolescents in line with quality standards
Clinical care of adolescents with specific conditions
  • Competency 3.1. Assess normal growth and pubertal development and manage disorders of growth and puberty
  • Competency 3.2. Provide immunizations
  • Competency 3.3. Manage common health conditions during adolescence
  • Competency 3.4. Assess mental health and manage mental health problems
  • Competency 3.5. Provide sexual and reproductive health care
  • Competency 3.6. Provide HIV prevention, detection, management and care services
  • Competency 3.7. Promote physical activity
  • Competency 3.8. Assess nutritional status and manage nutrition-related disorders
  • Competency 3.9. Manage chronic health conditions including disability
  • Competency 3.10. Assess and manage substance use and substance use disorders
  • Competency 3.11. Detect violence and provide first-line support to the victim
  • Competency 3.12. Prevent and manage unintended injuries
  • Competency 3.13. Detect and manage endemic diseases

In addition to these general competencies, WHO has defined an adolescent-friendly provider in its Adolescent Friendly Health Services: An Agenda for Change as one who:

  • Possesses technically competent in adolescent-specific areas, and offers health promotion, prevention, treatment and care relevant to each client’s maturation and social circumstances;
  • Has interpersonal and communication skills;
  • Is motivated and supported;
  • Is non-judgmental and considerate, easy to relate to and trustworthy;
  • Devotes adequate time to clients or patients;
  • Acts in the best interests of their clients;
  • Treats all clients with equal care and respect; and
  • Provides information and support to enable each adolescent to make the right free choices for his or her unique needs.
Practical examples of how health providers can be youth-friendly
  • Show adolescents that they enjoy working with them.
  • Counsel in private areas where they cannot be seen or overheard, ensuring confidentiality and assuring the client of confidentiality.
  • Listen carefully and ask open-ended questions such as, “How can I help you?” and “What questions do you have?”
  • Use simple language and avoid medical terms.
  • Use terms that suit young people, avoiding terms such as “family planning,” which may seem irrelevant to those who are not married.
  • Welcome partners and include them in counseling, if the client desires.
  • Try to make sure that a young woman’s choices are her own and that she is not pressured by her partner or her family. In particular, if she is being pressured to have sex or to not use condoms, providers should help a young woman think about, and practice, what she can say and do to resist and reduce that pressure.
  • Speak without expressing judgment (say, for example, “You can” rather than “You should”), and avoid criticizing the adolescent even if the provider does not approve of what the adolescent is saying or doing. The provider should help adolescents make decisions that are in their best interest.
  • Take time to address fully questions, fears and misinformation about sex, STIs and contraceptives. Many adolescents want reassurance that the changes in their bodies and their feelings are normal. Providers should be prepared to answer common questions about puberty, monthly bleeding, masturbation, night-time ejaculation and genital hygiene.
Assess your facility against existing standards
Perception is just as important as reality for young people. If your facility is not seen to be youth-friendly amount the young people in the catchment area, then they will not come. Management, providers, and other staff must all work to promote the perception that services are meant for young people and that they meet existing standards.

There are a number of tools that can be used to assess the extent to which a facility is offering adolescent and youth-friendly services. Here are some examples:

These assessments assess the facility and services provided against the global standards.

Questions to consider when assessing a facility’s characteristics
  • Branding (stigma-free): Do you market your facility as a youth-friendly center? (e.g., separate brand name for the youth-friendly services within your facility, logo that doesn’t picture a family, facility name that doesn’t include “family planning”) Does the signage on the front of your facility welcome young people?
  • Convenient location (accessible): Is your facility easy to find? (e.g., sign posted from the main road)? Is your facility within walking distance of a public transport hub?
  • Convenient opening hours (accessible): Is your facility open during after-school hours and/or on weekends? Are there specific hours for young people? Does your facility have an easy appointment system for young people to use? (e.g., walk-in clinic, appointment system, emergency appointments)
  • Reception area (privacy): Is the average waiting time satisfactory for young clients? Can clients speak to the receptionist without being overheard by other clients? (e.g., clients can write down what service they need, separate entrance, separate waiting area, etc.)
  • Affordable fees (accessible): Does your facility provide subsidized and/or free services for young people? If no, can young people receive SRH services regardless of their ability to pay? Do you display the prices of your services clearly for clients to see? Does your facility have a strategy in place to ensure sustainability of subsidized services (e.g., fundraising strategy, focus on fee-paying clients, etc.)?
  • Consultation rooms (privacy): Are the consultation areas away from public view? Are the consultation rooms marked in a neutral way (i.e., no name of the service provided), so as to avoid stigmatization? Are the consultation areas soundproof?
  • Confidentiality: Are clients’ files stored securely, so that only the relevant service provider(s) can access them? Are young clients asked before their personal information is shared with third parties? If cases are shared between health providers for learning purposes, are clients’ details left out to ensure anonymity? Is the client given the option to provide the most appropriate address for maintaining their right to privacy, as opposed to requiring a home address? (e.g., post, email, phone call, SMS, etc.)

While some aesthetic and structural improvements to a facility add to its youth-friendliness, especially those that encourage privacy and confidentiality, it’s important not to oversimplify. A fresh coat of paint doesn’t replace a trained provider or a full stock of contraceptive supplies. And, if services aren’t affordable for young people, it won’t matter what the facility looks like. As a result, removing or reducing user fees or providing vouchers and cash transfers to adolescents and young people may be required.

Solicit feedback from adolescents and youth who visit your facility
As part of the assessment, engage adolescents and youth. There’s no better way to ensure whether or not young people find your facility to be youth-friendly than engaging them in the process of defining what it would look like. It can be as simple as holding focus groups and running through the different criteria that matter to them when accessing facility-based services.

Ask young clients:

  • How they found out about your facility
  • If they would refer the service to their peers
  • If they felt respected
  • If their privacy was protected
  • If they received the services they came for or were denied on the basis of age, marital status, or other markers

Setting up a facility advisory committee that includes some young clients would enable regular quality improvement for the facility, and ensure that young people can hold the facility accountable. Toolkits like IPPF’s Provide: Self-Assessment Tool for Youth-friendly Services can also support ongoing self-monitoring. Using monitoring tools and disaggregated data on client age, sex, parity and service type, facilities can be very responsive to the needs and realities of the young people in their vicinity. It is important to act on the results and recommendations coming from these feedback mechanisms as well as those from the assessments. Young clients should be able to see that their opinions and needs and listened to and acted upon at the facility.

Programmatic example: Young researchers determine youth-friendliness in Malawi and Bangladesh

Rutgers and the International Planned Parenthood Federation (IPPF) trained young people as researchers in Malawi and Bangladesh. A two-week intensive training included topics such as sexual and reproductive health, qualitative research methodologies and data analysis. Over an extended period, the young researchers were engaged in interviews and focus groups with peers who had accessed services at health clinics (both urban and rural) to determine the extent to which young people’s expectations were met by each clinic. Results from Malawi indicated that young people were drawn to facilities depending upon how confidential they were, the availability of services, friendliness of providers and the cost of services.

Develop and deliver a training curriculum
Evidence indicates that training for health providers should include not only information about adolescent development and health but also their rights (Evidence to Action, 2014). Trainings should also include information on the social determinants of health; in urban environments, trainings should include information on how to reach and provide services to key populations. Integrate “values clarification and attitude transformation” components into health provider trainings, encouraging reflection on the socio-cultural biases that impact their work. Promote doing good, not just doing no harm; and support, rather than blame, health providers as they implement new practices.

Illustrative provider training topics
Health service providers should receive training on but not limited to:

  • Essential package for AYFS
  • Value clarification and attitude transformation training on adolescent and youth sexuality and provision of services such as contraception
  • Characteristics of adolescent growth and development (including neurobiological, developmental and physical) which impact health
  • Privacy and confidentiality

In the absence of pre-service training on adolescent SRH, training can take place as part of on-the-job training or whole site orientation. See this agenda for an example of six training sessions that can be included as a whole site orientation training schedule. Include administrative, cleaning and laboratory staff in trainings on youth-friendly services to ensure that young clients’ interactions with all staff members at service delivery points are positive.

NURHI Pilots 3 New Approaches to Overcoming Provider Biases

In an effort to help providers overcome their biases related to family planning services for young people, the Nigerian Urban Reproductive Health Initiative (NURHI) has piloted three approaches: the fishbowl approach, a values clarification exercise and videos.

The fishbowl approach works by facilitating a roundtable discussion with providers and clients. The discussion starts with the clients sitting in an inside circle, with providers sitting around an outside circle. During the dialogue, only participants in the inner circle are allowed to talk. They are asked to share their experiences, including how they were treated by a provider, if they got the services they wanted, or the consequences they faced for not receiving the requested services. Then, the clients and the providers switch places, giving the providers a chance to speak about their challenges, including being overworked, having to see too many clients, or not receiving pay for several months. These dialogues have been an eye-opening experience for both clients and providers and have helped dispel misconceptions that providers are inhumane and show providers that there can be dire consequences for clients who do not receive the appropriate care.

The values clarification exercise works by having people examine their own perceptions. NURHI asks providers to agree or disagree with statements about their values and then discuss why they agree or disagree. After a group discussion, they link what people say back to the National Family Planning / Reproductive Health Service Protocols to determine the appropriate recommendations for service provision.

Finally, NURHI has developed two videos to depict client-provider interactions with young people. Given responses shared by young people themselves, the videos show interactions with a supportive and an unsupportive provider (these terms are chosen carefully, as not to dissuade providers from using the videos by deeming them as friendly or unfriendly). So far, these videos have been received positively because they allow the provider to identify and reflect on their behaviors on their own terms.

Put in place systems and resources for ongoing support for health providers
Provide ongoing training and support. One-off trainings are not effective at improving the quality of or demand for youth-friendly SRH services. Ongoing reinforcement—including supportive supervision, job aids, and mentoring—is required to ensure that providers can meet the needs of youth, and are encouraged to be advocates for young people’s SRHR.

  • Provide job aids for health providers that are easy to access during or between consultations.
  • Establish case management support groups for health providers to discuss cases and best practices in SRH provision to young people.
  • Support a mentorship scheme in place for health providers to learn from one another.
  • Identify “early adopters” of youth-friendly services and make them champions of the cause.

This video demonstrates effective ways to talk to young women about long-acting reversible contraceptive methods (LARCs). Also available is a video discussion guide to help program managers or health facility senior staff facilitate deeper dives into the video’s key messages, including provider bias.
HC3 | Talking about LARCs with Young Clients: A Video for Providers (English) HC3 | Talking about LARCs with Young Clients: A Video for Providers (French)

Establish monitoring, evaluation and accountability systems
Systems should be in place to collect and analyze data on health providers’ competencies related to adolescent SRH as well as service delivery statistics on the services sought by adolescents and youth, disaggregated by age, sex, parity and service type. Hold regular meetings with staff to review services statistics. Identify data quality issues in terms of gaps in recordkeeping as well as analyze what the data on adolescents and youth tells you given the population in your catchment area. Are adolescents and youth represented in the data? What segments are missing?

Develop partnerships with youth-led organizations that can help monitor youth-friendliness of services (both of the provider and facility) using mystery client, focus group, or other data collection methodologies. These data should be discussed regularly with health providers to ensure quality improvement.

Additionally, program implementers should develop systems for situations wherein young people’s sexual and reproductive rights (SRR) have been violated by a health provider. Health providers should remain accountable to young people for the delivery of rights-based SRH services.

What Is the Evidence?

  • A project on mainstreaming youth-friendly services in Mozambique and Tanzania demonstrated an increase in new contraceptive users among 10-24 year olds, and a significant number of young clients reported satisfaction with the services and being treated with respect by the service providers (Pathfinder International, 2017).
  • In Nigeria, nurse/midwives trained by the Nigeria Urban Reproductive Health Initiative (NURHI) had significantly lower age bias (refusing to offer a method to a person age 15 or older) for male condoms, pills, EC, injectables, and IUDs compared to those nurse/midwives who received non-NURHI in-service family planning training and those who did not receive any training at all (NURHI, 2017).
  • Evidence from urban Senegal suggests that male providers, nurses, and older staff may be more likely to apply restrictions to contraceptive access based on clients’ age and/or marital status (Sidze et al., 2014).
  • A literature review on young people’s perspectives on health care revealed that there are eight indicators which are central to young people’s positive experience of care: accessibility of health care; staff attitude; communication; medical competency; guideline-driven care; age appropriate environments; youth involvement in health care; and health outcomes (Ambresin et al., 2013). Another literature review on evidence for improving adolescent access to and use of SRH services highlights that the most effective interventions in increasing adolescents’ and young people’s access to services is to ensure that, other than quality clinical services, sexuality and life skills education, and linkages with educational and economic opportunities and supportive adults are in place (Denno et al., 2015).
  • Evaluations of young people’s access to services shows that competent health providers alone is not enough to increase young people’s access to SRH services (Chandra-Mouli et al., 2015; Dick et al., 2006). Approaches to scaling up services should use four complementary approaches:
    • Providers are trained and supported to be nonjudgmental and friendly to adolescent clients
    • Health facilities are welcoming and appealing
    • Communication and outreach activities inform adolescents about services and encourage them to make use of services
    • Community members are supportive of the importance of providing health services to adolescents

Take An Assessment and Get a Certificate

Helpful Tips

Youth participation

  • As you’re reviewing the youth-friendliness of your service delivery point by going through WHO SEARO’s Supervisory/Self-Assessment Checklist for Adolescent Friendly Health Services or IPPF’s Provide, ask some of your young clients to fill it out on their own and compare your answers.
  • Include young people as experts in health provider trainings.
  • Involve young people in monitoring, evaluation, and accountability mechanisms aimed at ensuring compliance with standards for health providers.

Data management

  • Toolkits like IPPF’s Provide can also enable ongoing self-monitoring of the facilities. Combined with disaggregated data on age, sex, and service type, facilities can be very responsive to the needs and realities of the young people in their vicinity.
  • Use data on youth to inform the content of trainings for providers, including data on key youth populations.
  • Ensure that health providers are aware of the most salient data on youth SRH in the context.

Multisectoral collaboration

  • There is no one-size-fits-all-approach, which is why it is important to reach adolescents with sexual and reproductive health services at different stages of need. Often, young people have more concerns on the social and mental aspects of sexual and reproductive health, rather than clinical services. Therefore, partnering with specialized services for referrals, based on an assessment of local needs, is important.
  • Link with training institutions that can provide ongoing and refresher trainings for staff.
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Challenges

  • Making any facility youth-friendly may require an initial injection of financial resources, including to make adjustments to clinic layout (construction and/or furniture) to respect young clients’ privacy.
  • There may be forces outside of the control of the facility that mean that it cannot meet all standards of youth-friendliness. For example, supply chain blockages may make it impossible to procure adequate commodities.
  • Monitoring and evaluation often requires (human) resources and expertise that some facilities don’t have, which means that there is no feedback mechanism to check the youth-friendliness of the facility.
  • Norms related to gender and sexuality form from a very young age. Changing these norms takes generations. Health provider trainings should include reflection on these norms and the adverse health consequences that they have, particularly for young women. Trainers should engage health providers continually in critical reflection and participatory learning. Youth-adult partnership may be another way that adult health providers can learn from young people about life experiences that reflect the harmful effects of patriarchy.
  • When young people are placed in a position of commenting on adult health providers’ competencies, there may be backlash. Health provider training should take this into consideration and raise awareness of the leadership role that young people can play in health, as well as how to enter into equal partnerships with young people.

Tools Related to This Approach

Guidelines and National Standards

India

Kenya

Nigeria

Senegal

Tanzania

Training Packages

References

See a listing of all AYSRH references.