AYSRH ToolkitDelivering Services for Youth
Adolescent & Youth-Friendly Services
What is it?
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 by communities, families, partners, and providers.
- Individual barriers, such as incomplete or incorrect knowledge of SRH, including myths and misconceptions around contraception; limited self-efficacy and individual agency; constrained ability to navigate internalized social and gender norms; and lack of access to information about what SRH services are available and where to seek services.
Youth 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 as clients (Senderowitz, 1999). 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). Developing AYFS without generating demand among youth through appropriate channels will lead to underused facilities, so it is essential that the two activities are linked together in TCI program designs and work plans.
In collaboration with partner organizations and national stakeholders, the World Health Organization (WHO) developed the following Standards-driven approach to improve the 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 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 suggesting facility-level data considerations and requirements.
What Are the Benefits?
- Facilitates youth access to and satisfaction with services
- Delivers higher-quality SRH services to youth
- Empowers health providers to be advocates for youth
- Encourages future health-seeking behavior among youth
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.
Step 1: Start local: 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, including them in 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:
If such standards do not exist and must be developed, young people and 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:
|Basic concepts in adolescent health and development, and effective communication||
|Laws, policies and quality standards||
|Clinical care of adolescents with specific conditions||
Step 2: Assess your facility against existing standards
Work with local government stakeholders to determine a target number of health facilities in the geography to assess against existing standards. Work with the facility quality assurance/improvement team to conduct the assessment, using tools such as:
- WHO SEARO’s Supervisory/Self-Assessment Checklist for Adolescent Friendly Health Services
- IPPF’s Provide: Self-Assessment Tool for Youth-friendly Services
- WHO’s Vol 3. Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards
TCI’s Hubs are in the process of adapting the WHO SEARO standards.
Perception is just as important as reality for young people. If your facility is not considered youth-friendly, then they will not come. Management, providers, and other staff must all work to promote the perception that services are meant for youth and meet existing standards.
|Questions to consider when assessing a facility’s characteristics|
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, 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 youth may be required. In Francophone West Africa, services are not free across much of the region. To address this structural barrier, TCI works with community health workers (CHWs) (locally referred to as community relays) and youth associations to offer coupons for free services to both married and unmarried youth.
Step 3: 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 determine whether or not young people find your facility to be youth-friendly than engaging them in the process of defining what that looks 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 your facility 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 youth will enable regular quality improvement 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 youth they serve. It is important to act on the results and recommendations coming from these feedback mechanisms as well as those from the assessments. Youth should be able to see that their opinions and needs and listened to and acted upon.
Programmatic example: Youth 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 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 their expectations were met by each clinic. Results from Malawi indicated that young people were attracted to facilities that demonstrated confidentiality, service availability and affordability, and provider friendliness.
Step 4: Develop and deliver a training curriculum
Use the data you collected via the assessment and youth feedback to develop your training curriculum and quality improvement plan. Prioritize low-performing facilities. 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 integrate information on the social determinants of health, and in urban environments, 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; support, rather than blame, health providers as they implement new practices. For an example of a health provider training with a particular focus on values clarification and attitude transformation, view TCI’s Francophone West Africa Hub’s agenda (in French).
|Illustrative provider training topics|
Among other topics, health service providers should receive training on the following:
In addition to the general competencies listed under step 1, in its Adolescent Friendly Health Services: An Agenda for Change WHO defines an adolescent-friendly provider as one who:
- Possesses technical competence in adolescent-specific areas, and offers health promotion, prevention, treatment and care relevant to each client’s maturity level and social circumstances.
- Has interpersonal and communication skills.
- Is motivated and supported.
- Is non-judgmental, considerate, relatable 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.
- Provides information and support to enable each client to make appropriate, voluntary choices for his or her unique needs.
- Shows adolescents that they enjoy working with them.
- Counsels in private areas where they cannot be seen or overheard, ensuring confidentiality.
- Listens carefully and ask open-ended questions such as, “How can I help you?” and “What questions do you have?”
- Uses simple language and avoid medical terms.
- Uses terms that suit young people, avoiding terms such as “family planning,” which may seem irrelevant to those who are not married.
- Welcomes partners and include them in counseling, if the client desires.
- Tries 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 consider and practice what she can say and do to resist and reduce that pressure.
- Speaks without expressing judgment (say, for example, “You can” rather than “You should”), and avoids criticizing the adolescent even if the provider does not approve. The provider should help young clients make decisions that are in their best interest.
- Takes 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.
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 and slide deck 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’ have positive interactions with all staff members .
NURHI Pilots 3 New Approaches to Overcoming Provider Biases
In an effort to help providers overcome their biases related to family planning services for youth, the Nigerian Urban Reproductive Health Initiative (NURHI) has piloted three approaches: the fishbowl approach, a values clarification exercise and videos.
The fishbowl approach is a facilitated 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 eye-opening for both clients and providers, dispelling misconceptions that providers are inhumane and showing providers that there can be dire consequences for clients who do not receive 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, then discuss their reasons. The session is designed to be held during any formal gathering or meeting, and it lasts for a maximum of an hour. The sessions involves the use of post-its, problem statements and ‘5-Why’ technique to stimulate insight which in turn can lead to behavior change.
Finally, NURHI has developed two videos depicting youth client-provider interactions. 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.
This video demonstrates effective ways to talk to young women about long-acting reversible contraceptive methods (LARCs). An accompanying video discussion guide helps program managers or senior staff facilitate deeper dives into the video’s key messages, including provider bias.
NURHI developed a distance-learning app, My Family Planning Guide, that is designed to meet the needs of providers for up to date, accessible information and tips to strengthen provider-client communication. Notably, the app has a chat room that enables providers to communicate in real time with colleagues across Nigeria.
Step 5: Establish 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—ensures that providers can meet young clients’ needs and encourages them to advocate for young people’s SRHR. In East Africa, TCI works with youth to serve as trainers and mentors; in India, TCIHC draws from a pool of AYSRH-trained coaches.
- Provide job aids that are easy to access during or between consultations.
- Establish case management support groups for health providers to discuss cases and best practices in youth SRH provision.
- Support the creation of a mentorship model for health providers to learn from one another.
- Identify “early adopters” of youth-friendly services and make them champions of the cause.
Step 6: 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 statistics on the services sought by youth, disaggregated by age, sex, parity and service type. Hold regular meetings with staff to review this data. Identify data quality issues in terms of gaps in recordkeeping, and analyze what the data tells you given the youth population in your area. Are youth represented in the data? What segments are missing?
TCI’s East Africa Hub uses the following indicators to assess AYFS effectiveness s:
- Number of service providers who have completed training on AYFS
- Proportion of family planning facilities providing quality AYFS
- Number of adolescents and youth counseled on AYSRH
- Number of adolescents and youth provided contraceptive methods (condoms and/or other method)
- Percentage of adolescents and youth who reported a positive experience when seeking services
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. This data should be discussed regularly with health providers to ensure quality improvement.
Additionally, program implementers should develop systems to address situations where a health provider violates a young client’s sexual and reproductive rights (SRR). The program must hold providers accountable 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 youth ages 10-24, and a significant number of young clients reported satisfaction with the services and respectful treatment by providers (Pathfinder International, 2017).
- In Nigeria, nurse/midwives trained by NURHI had significantly lower age bias for male condoms, pills, emergency contraception, injectables, and IUDs compared to nurse/midwives who received non-NURHI in-service family planning training and those who received no training at all (NURHI, 2017).
- Evidence from urban Senegal suggests that male providers, nurses, and older staff may be more likely to restrict 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 eight indicators central to their 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 the evidence for improving adolescent access to and use of SRH services highlights that, in addition to quality clinical services, the most effective intervention is providing sexuality and life skills education and linking youth with educational and economic opportunities and supportive adults (Denno et al., 2015).
- Evaluations show that competent health providers alone are not enough to increase youth 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
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Health providers’ biases are often cited as a major barrier to sexual and reproductive health (SRH) services, but evidence shows that ongoing training of health providers on the unique needs of young people has the potential to transform services into an experience that is empowering for young people.
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.
What are some examples of how health providers can be youth-friendly?
Which of the below are essential elements of youth-friendly services?
When young people visit a facility that is ill-equipped with supplies, closed at the time of their arrival, or perceived to be unsafe or unclean, they may be discouraged from returning to that facility. This may be especially true for young people who have to travel to a facility, especially if they are spending money or taking time off from school to do so. When adolescents find clean, friendly, well-stocked facilities, they are more likely to return.
How do you intend to use the information reviewed and/or tools that you accessed?
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- As you review 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 youth as experts in health provider trainings; make an extra effort to include representatives from sub-populations such as younger adolescents, rural youth, married youth, and ethnic and sexual minorities.
- Involve youth in monitoring, evaluation, and accountability mechanisms aimed at ensuring compliance with standards for health providers.
- Toolkits like IPPF’s Provide can also enable facilities to self-monitor. Combined with disaggregated data on age, sex, and service type, facilities can be very responsive to the needs and realities of the youth in their vicinity.
- Use data on youth to inform the content of provider trainings , including data on key youth populations.
- Ensure that health providers are aware of the most salient data on youth SRH in their context.
- There is no one-size-fits-all-approach, which is why it is important to reach adolescents with SRH services at different stages of need. Often, young people are more concerned about 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.
- Making any facility youth-friendly may require an initial injection of financial resources, including making adjustments to clinic layout (construction and/or furniture) to respect young clients’ privacy.
- There may be forces outside the facility’s control that prevent it from meeting 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 gauge the facility’s youth-friendliness.
- Norms related to gender and sexuality develop from a very young age, and changing them takes generations. Health provider trainings should include reflection on these norms and the adverse health consequences they may have, particularly for young women. Trainers should consistently engage health providers in critical reflection and participatory learning. Youth-adult partnerships may be another way that health providers can learn from young people about life experiences.
- When young people are placed in a position of commenting on adult health providers’ competencies, there may be a strong negative reaction. 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 youth.
Tools Related to This Approach
Guidelines and National Standards
- Global Standards for Quality Health-Care Services for Adolescents, WHO
- Making Health Services Adolescent-Friendly: Developing National Quality Standards for Adolescent Friendly Health Services, WHO
- WHO recommendations on adolescent sexual and reproductive health and rights, WHO
- Core competencies in adolescent health and development for primary health care providers (English | French | Spanish), WHO
- Global Sexual and Reproductive Health Package for Men and Adolescent Boys, IPPF
- National Youth Policy, 2014
- The Rashtriya Kishor Swasthya Karyakram (RKSK), 2014 (National Adolescent Health Strategy)
- National Adolescent Sexual Reproductive Health Policy Implementation Framework, 2017-2021
- National Guidelines for Provision of Adolescent and Youth Friendly Services in Kenya (2016)
- National Adolescent Sexual and Reproductive Health Policy (2015)
- National Guidelines on Promoting Access of Young People to Adolescent and Youth-Friendly Services in Primary Health Care Facilities in Nigeria, 2013
- National Guidelines for the Integration of Adolescent and Youth Friendly Services Into Primary Health Care Facilities in Nigeria, 2013
- Clinical Protocol for the Health and Development of Adolescent and Young People in Nigeria, 2011
- National Family Planning/Reproductive Health Policy Guidelines and Standards of Practice, 2005
- The Training Resource Package for Pre-Service Education in Family Planning and Adolescent and Youth Sexual and Reproductive Health, E2A Project
- Adolescent and Youth-Friendly Health Services: Modular Training – Facilitator Manual, Elizabeth Glaser Pediatric AIDS Foundation/Lesotho
- Training manual on adolescent and youth sexual and reproductive health and the provision of adolescent and youth-friendly services, EngenderHealth (English | French)
- Youth-friendly services for married youth: A curriculum for trainers, EngenderHealth (includes COPE© Self-Assessment Guides)
- Youth-friendly Health Services Training Manual: Participant Handbook, Malawian Ministry of Health (intended as a five-day standalone training)
- Orientation programme on adolescent health for health-care providers, WHO
- Making Your Health Services Youth-Friendly: A Guide for Program Planners and Implementers (English | French | Spanish), PSI
- Facilitator’s Guide: Training Health Providers in Youth-Friendly Health Services, PSI
- Providing Reproductive Health Services to Young Married Women and First-time Parents in West Africa: A Supplemental Training Module for Facility-based Health Care Providers (English | French), Pathfinder International
- Providing Reproductive Health Services to Young Married Women and First-time Parents in West Africa: A Supplemental Training Module for Community Workers Conducting Home Visits (English | French), Pathfinder International
- Meeting the SRH Needs of First-time Parents & Young Married Women in Tanzania Training Package (Swahili), Pathfinder International
- Conducting Home Visits and Providing Counseling and Contraceptive Services to Young Women, Including First-Time Mothers in Akwa Ibom, Nigeria A Supplemental Training Module for Community Health Extension Workers, E2A Project
- Adolescent Job Aid, WHO
- Cue Cards for Counseling Adolescents on Contraception (English | French | Portuguese | Spanish), Pathfinder International
- Adolescent Age & Life-Stage Assessment and Counseling Tools, MCSP
- National Adolescent & Youth Friendly Job Aids for Service Providers in Primary Health Care Facilities in Nigeria, Federal Ministry of Health
- Talking about LARCs with Young Clients (English | French), HC3