Adolescent-Responsive Contraceptive Services
What is it?
There is growing recognition of the need to make existing health services adolescent-responsive instead of using separate space models (e.g., offering adolescent-friendly services in a separate room within an existing health facility) (USAID, 2015). Adolescent-responsive contraceptive services (ARCS) represents a systems approach to making existing contraceptive services adolescent-responsive by incorporating elements with demonstrated effectiveness for increasing adolescent contraceptive use; see box below (HIP Enhancement).
TCI has operationalized this HIP enhancement across all of its geographies.
What Are the Benefits?
- Facilitates youth access to and satisfaction with contraceptive services
- More sustainable approach given that assessing adolescent-responsive services can be easily integrated into routine Ministry of Health quality improvement/assurance supervisory visits
- 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?
Ensure an enabling policy and legal environment for contraceptive provision to adolescents
Many areas of law and policy impact youth access to SRH services and information; some impact directly, while others have an indirect influence. Below is a short, non-exhaustive list of the different areas of law and policy to keep in mind when implementing adolescent and youth sexual and reproductive health (AYSRH) programs.
|Area of law||How it impacts service provision|
|Sexual consent||Sexual consent laws may determine the age at which a person can legally consent to sexual activity, as defined in the law. In many places, this is set at 16 or 18 years of age, though it may be different for same-sex sexual activity.|
|Rape||Criminal law defines what type of conduct is considered “rape.” In many places, sex with a young woman under a certain age (e.g., 16) is criminalized in every circumstance; this is sometimes known as “statutory rape.” These provisions are often interpreted as setting the minimum age of sexual consent. These laws may also be gendered, in that young men’s experiences of rape are excluded from the legal definition.|
|Child protection||Child protection laws may place a duty of care on health providers to report certain information to third parties (e.g., police, social services) if they believe harm will come to a child in their care. In some contexts, health providers may be required to report children under a certain age who are engaged in sexual activity.|
|Medical consent||Medical consent laws often determine an age at which a person can independently consent to medical services. In some places, different ages apply to invasive procedures (e.g., surgery) and non-invasive ones. At times, the age of medical consent can be different for SRH services than for other health services.|
|Age of majority||Age of majority laws set the age at which young people are considered to be legal adults; this is often 18 years. In some contexts, the age of majority is confused with the age at which young people are legally able to consent to sex or access SRH services. It also influences how adults view young people under the age of majority.|
|Age of marriage||Age of marriage is the age at which a person can legally consent to marriage. The internationally-accepted minimum age of marriage is 18, although in some jurisdictions marriage below this age is allowed under customary law or in cases where parents give their consent. In some places, spousal consent is needed in order for women to access contraceptives even where their use is now legal before marriage.|
|SRH||SRH laws specify the services to be provided by the government to the population. The law may also mandate certain agencies (e.g., ministries of health) to provide services. In addition to primary legislation (acts, statutes), some countries also set out secondary legislation (policies, regulations, strategies, orders) that provide more detail as to how the primary legislation is to be implemented.|
|Comprehensive sexuality education (CSE)||CSE laws set out the topics to be included and the age groups that will receive CSE in schools, as well as the qualifications required of educators. Good CSE laws also make provisions for out-of-school young people, which is of great importance in urban environments.|
- Assess existing national and sub-national laws and policies. Compare and contrast them with international human rights norms and evidence of what works with regard to young people’s sexual and reproductive health.
- Determine the extent to which national and sub-national laws and policies are being implemented in practice, and what the impact is on youth.
- Familiarize yourself with national guidelines and packages of essential services for young people at different levels of the health system.
- Ensure copies of relevant laws, policies, guidelines, and adolescent-friendly service standards where they exist are widely available. Provider trainings and follow up support at facility level should reflect these legal rights, policies, guidelines, and standards.
- Speak with youth, perhaps using focus groups or interviews, to determine how laws and policies impact their ability to seek and access SRH services, information, and education.
- Develop an advocacy strategy with youth.
TCI’s Success Advocating for Youth-Friendly Cities
Engage the private sector and integrate services to meet the needs of different adolescent segments
Although TCI’s primary focus is on strengthening the capacity of the public sector to leads its family planning program, TCI recognizes the important role that the private sector plays, especially in reaching and addressing the family planning needs of the urban poor. As a result and in light of COVID-19, TCI adapted its strategy to engage the pharmacies to bridge service delivery and ensure access to all women but especially youth have readily available access to short-term methods. This approach was rollout in East Africa and Nigeria.
Pharmacy Approach in Action In East Africa
TCI went from engaging 184 in 2019 to 760 in 2021 across Kenya, Tanzania and Uganda. Through this engagement, TCI holds capacity building sessions on family planning and youth-friendly services for relevant pharmacy staff, establishes a referral system whereby pharmacists refer clients to the closest TCI-supported health facility for methods that they cannot dispense and record and report the number and age of clients counseled on family planning methods and sales of different types of methods in pharmacies in their logs but also transferring this data to the closest TCI-supported health facility for input into the national health management information system (HMIS) – so that the data can inform family planning program planning of the entire area.
In addition, it is important to integrate contraceptive products and services into other health services, especially services that adolescents readily seek (e.g., HIV and MNCH) — this is especially important in an environment that requires parental consent for minors to obtain contraceptive services, such as Philippines.
IRR of RA 10354, Section 4.07 Access of Minors to Family Planning Services Any minor who consults at health care facilities shall be given age-appropriate counseling on responsible parenthood and reproductive health. Health care facilities shall dispense health products and perform procedures for family planning provided that in public health facilities, any of the following conditions are met:
(a) The minor presents written consent from a parent or guardian.
This is why TCI’s immediate postpartum family planning intervention is so important in the Philippines in reaching first-time parents with family planning information and services.
- Understand the context and realities of adolescent and youth to identify where they seek services. Health services can be delivered through schools and workplaces, youth centers, households, streets or markets, and drug shops and pharmacies.
- Build the capacity of those trusted providers to better serve youth. Knowing who the trusted community members are, and where youth already go for services, enables your program to tap into existing, credible resources for increasing contraceptive uptake or other SRH services.
- Establish partnerships with the private sector to enable non-traditional service delivery. Ensure a functional referral system is in place so that private sector providers can refer clients to public health facilities for methods they do not offer or cannot dispense.
- Ensure supportive supervision and ongoing capacity building support by conducting site visits to pharmacies and private sector facilities to evaluate the quality of services and continue to build capacity. Monitor and evaluate the documentation and reporting tools of the pharmacy on a quarterly basis in line with the MOH policy and procedures.
Link ARCS with social and behavior change interventions
It is not enough to focus on just improving the service delivery environment. One must generate demand among adolescents and youth through appropriate channels to ensure that they access adolescent-responsive contraceptive services. Therefore, social and behavior change interventions that address adolescent-specific cognitive, cultural, and social challenges and barriers should be intentionally linked together in TCI program designs and workplans.
These SBC interventions may include:
|Interpersonal Communication (IPC)||
In the case of TCI, interpersonal communication often takes place through home visits that community health workers (CHWs) make to youth and their families. The CHW provides counseling at repeat sessions and offers referrals to local youth-friendly health services, accompanying youth clients where needed.
In India, TCI coaches urban Accredited Social Health Activists (ASHAs) on tailored messages and counseling techniques to be used with the following groups:
● First-time mothers and fathers
● Women 7 to 8 months pregnant or immediately postpartum
● Decision-makers in the family, such as in-laws and parents
In Nigeria, Community Health Extension Workers and non-clinical providers were trained on IPC and and counseling skills as part of the Nigeria Urban Health Initiative (NURHI). Training was supplemented with a mobile app for refresher trainings. This approach has been continued under TCI.
Prior community mobilization through community health workers/social mobilizers/volunteers/youth groups or other means is critical to the success of in-reach and outreach services. Experience shows that without a community mobilization component, turnout for in-reach activities is limited and outreach efforts are less successful. Increasing the knowledge of potential family planning clients and creating an atmosphere that promotes family planning ensures greater demand and uptake of services. Refer to the Nigeria ‘Get it Together’ Youth Social Mobilization: from Strategy Design to Implementation for more information.
TCI makes sure that community health workers and social mobilizers refer potential clients to services using referrals/go cards/coupons, depending on the geography. This helps with monitoring these activities. In addition, TCI East Africa uses sentinel surveillance sites – a small number of health facilities – to collect data on clients’ source of referrals; CHWs are among the top reported.
Community theater and drama groups are actively engaged to inform youth and the wider community about SRH issues in an entertaining way while providing referrals to services. This approach is particularly used in East Africa and Nigeria.
In India, city officials supported by TCI commemorated Adolescent Health Days at select urban primary health centers to drive access and acceptance of health services among youth. A total of 75 adolescents participated in this event, including 16 boys and 33 girls from a younger cohort (15-19 years of age). This half-day event, named #Haseen Sapne (“chit-chat”), offered a variety of infotainment activities like a gaming zone, information area, nutrition corner, male/female counseling corner, and talk show with an ARSH doctor/counselor.
In addition, September 2018 a high-intensity mid-media campaign was launched in the five AYSRH pilot cities of Uttar Pradesh: Allahabad, Varanasi, Gorakhpur, Firozabad and Saharanpur. Using various media approaches including IVR (missed call and SMS) and street theater, it reached around 130,000 young married couples with messages on the benefits of family planning (protection from unwanted pregnancy) and information about quality FP services at government health facilities.
Building off of the successful brand of NURHI’s “Get It Together” campaign, TCI works with States to adapt and air TV and radio spots.
Francophone West Africa launched its “Je choisis” umbrella communication campaign in Abomey-Calavi and UCOZ on World Contraception Day (September 26, 2019). It is currently producing two radio spots to encourage men and women to choose FP and inform the public of available FP services. The messages in the radio spots will also be converted into posters featuring local figures from each city. In Nigeria and East Africa, TCI supports local government and community stakeholders to leverage community radio programs to get messages out about family planning and AYSRH. In India, TCI designed an integrated family planning mass media campaign with the National Urban Health Mission in Uttar Pradesh.
Improve providers’ competency in providing ARCS
|WHO’s Definition||Health-care providers demonstrate the technical competence required to provide effective health services to adolescents. Both health-care providers and support staff respect, protect and fulfill adolescents’ rights to information, privacy, confidentiality, non-discrimination, non-judgmental attitude and respect.|
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 guidelines do not exist and must be developed, review WHO’s Core Competencies in Adolescent Health and Development for Primary Care Providers and engage youth and youth organizations are crucial allies in ensuring that they are youth-responsive and context-specific.
- Assess health facility against the existing standards to see if you have staff already trained in adolescent and youth-friendly health services (AYFHS).
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 has adapted the WHO SEARO Supervisory/Self-Assessment Checklist to best suite each country’s context, aligning with existing supportive supervisory tools.
- Train providers to offer AYFHS, focusing on improving provider knowledge and competencies so that they can offer a full range of contraceptive options as well as overcoming provider bias.
Based on the data from the assessment, prioritize low-performing facilities and develop your training plan. 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). Training should include providing nonjudgmental information and services; accurate information on medical eligibility criteria for adolescent contraceptive use; legal policies and rights of adolescents to services and information; values clarification on adolescent sexuality; and skills on how to communicate with adolescent clients (HIPs, 2015). 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 this training curriculum adapted by TCI’s Francophone West Africa Hub (in French) or any of the other curriculums under Training Packages on the right hand side of this page.
|Illustrative Provider Training Topics|
Among other topics, health service providers should receive training on the following:
Example of Tools for Overcoming Provider Biases in Nigeria
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.
Example of Tools for Overcoming Provider Bias Related to Youth & LARCs
This video developed by the Health Communication Capacity Collaborative 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.Overcoming Provider Bias Related to Youth and LARCs
- Use a whole-site orientation approach to train on YFS
In the absence of pre-service training on YFS, 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 AYFHS to ensure that young clients’ have positive interactions with all staff members. This approach will help ensure adolescent-friendly care is not invested in only one provider and that youth do not experience resistance from support staff, such as an intake nurse or pharmacist.
- Reinforce training through supportive supervision, job aids and mentorship to change behavior attitudes and behaviors.
Provide ongoing training and support. One-off trainings are not effective at improving the quality of or demand for AYFHS. 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.
- 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 AYFHS and make them champions of the cause.
In East Africa, TCI works with youth to serve as trainers and mentors and in India, TCIHC draws from a pool of AYSRH-trained coaches.
Example of Ongoing Digital Support Tools for Providers
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.
In addition, in Taraba State, TCI created a WhatsApp Group to provide constant mentorship and coaching to Family Planning/Reproductive Health (FP/RH) Coordinators, ranging in age (from 30 to 55-years old) and experience, on all aspects of family planning and AYSRH. The purpose of the WhatsApp Group was to stimulate real-time sharing of reports, facilitate exchange of best practices among the FP/RH Coordinators and provide problem-solving support by responding to challenges faced by the FP/RH Coordinators in record time. This technical brief outlines how WhatsApp is being used for continuous coaching, the steps that were taken to setup the WhatsApp Group, tips for sustaining use of the platform and results from its use.
Collect and use data to design, improve and track ARCS implementation
Systems should be in place to collect and analyze data on health providers’ competencies related to AYFHS, 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 record-keeping 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 AYFHS effectiveness:
- Number of service providers who have completed training on AYFHS
- Proportion of family planning facilities providing quality AYFHS
- Number of adolescents and youth counseled on SRH
- 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.
For more information on TCI’s approach to making adolescent and youth data visible, check out our approach on Data Collection & Use.
Address financial barriers to adolescent contraceptive use
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.
Support meaningful participation and leadership of adolescents
TCI engages youth as essential, active participants across family planning programming domains – through our demand generation activities with fellow youth, advocacy efforts nested within formal and informal structures to foster broad participation, and the design of services to increase access by honoring youth’s sexual and reproductive health rights and needs. This engagement occurs at both the community and governance levels across all hubs.
- Integrate youth throughout the project lifecycle to ensure accountability.
- Institutionalize and mainstream youth participation and leadership at all levels of the project – at the governance level as well as the community and facility levels.
- Solicit feedback from adolescents and youth who visit your facility. 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
- Provide capacity strengthening opportunities for youth to be able to effectively contribute to advocacy, governance, and accountability efforts.
- Set up a facility advisory committee that includes youth who will become part of regular quality improvement mechanisms and fora. Youth should be able to see that their opinions and needs and listened to and acted upon.
- Monitor and track the impact of youth engagement.
For more information on how to ensure youth participation, check out TCI’s Youth Participation & Engagement approach.
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).
- 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
- 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).