AYSRH Toolkit

Service Delivery

Adolescent and Youth-Friendly Health Services

by | Dec 18, 2017

Adolescent & Youth-Friendly Health Services

High-Impact Practice
Gender Intentional

What is it?

Adolescent and youth-friendly health services (AYFHS) (also called youth-friendly services, YFS) are designed to address the barriers faced by youth in accessing high-quality sexual and reproductive health (SRH) services.

  • 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.

There is growing recognition of the need to make existing health services youth-friendly instead of having stand-alone for delivery contraceptive services to adolescents and youth (USAID, 2015). Research also shows that provider bias towards unmarried youth accessing contraceptives is a persistent problem, with no geographic or cultural bounds. Discrimination towards young people manifests in many shapes and forms at facilities—from refusing to provide contraceptives to unmarried youth, to only informing young women about short-term methods. TCI supports ministries of health (MOH) and health departments to conduct technical and values-clarification exercises with health providers and equips them with the knowledge and tools to provide non-judgmental, supportive care to young people, regardless of their age and marital status. 

In collaboration with partner organizations and national stakeholders, the World Health Organization (WHO) developed a Standards-driven approach to improve the quality of health-care services for adolescents. These standards help minimize variability and ensure a minimal required level of quality to protect adolescents’ rights in health care (Nair et al., 2015). Many countries have developed their own national AYFHS checklists based on these standards, but they are still in the process of institutionalizing these checklists into the MOH’s quality improvement/assurance systems. TCI’s strategy is to catalyze the use of the AYFHS checklists to help MOH prioritize follow-up actions that improve the quality of service delivery for adolescents and youth.

This AYFHS approach focuses on guidance and tools to operationalize WHO’s standards 3-8, while the following standards have their own dedicated approaches:

NOTE: It is not enough to focus on just improving the service delivery environment. One must generate demand among youth through appropriate channels to ensure that they access youth-friendly services. As a result, AYFHS cannot be truly achieved without demand generation activities. Therefore, these activities should be intentionally linked together in TCI program designs and workplans.

What Are the Benefits?

  • Facilitates youth access to and satisfaction with services
  • Institutionalizes use of AYFHS standards in routine MOH 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?

Guidance, steps and tools are available below to operationalize the various WHO's standards 3-8 below.

Standard 3: Appropriate Package of Services
WHO's Definition The health facility provides a package of information, counseling, diagnostic, treatment and care services that fulfills the needs of all adolescents. Services are provided in the facility and through referral linkages and outreach.

In low-resource settings, financial and infrastructure limitations may restrict health systems’ ability to provide “one-stop shops” for all the health services that young people need. While the full continuum of SRH services should always be available for young people through referral, many service-providing institutions opt to develop packages of “essential services” that meet the most urgent needs of their youth population. The process of determining the essential package should be undertaken in partnership with young people, including urban young people and marginalized populations. Below is one example of a comprehensive package of SRH services for young people. 

Example: Rutgers
  • HIV testing, counseling, and treatment
  • STI testing and counseling
  • Prescribing appropriate medications and health products
  • Pregnancy testing
  • Contraception counseling and provision (“family planning” services)
  • Maternal health services
  • Abortion-related services and post-abortion care (within the extent of the law)
  • Counseling services: Sexual abuse counseling – Relationship counseling – Counseling and psycho-social support relating to individual issues that undermine sexual health and well-being – Sexual and gender-based violence counseling
  • Referral services (including outside of the health sector, such as legal and social services)

Steps:

  1. Familiarize yourself with national guidelines and packages of essential services for young people at different levels of the health system.
  2. Partner with young people residing in urban environments to define the package of services that would best fit their needs. 
  3. Discuss and decide upon the package of services that is feasible to provide, based on considerations of funding, facilities and human resources.
  4. Ensure that health providers possess the skills, competencies and attitudes to provide all health services on offer.
  5. Ensure a robust referral system is in place for all health services that are not available at your delivery point.

*Consider integrating services to meet the needs of youth at different stages of life and with a variety of health needs. Research shows that providing robust referral systems or integrating YFS services with the following are effective:

  • Numerous costing studies demonstrate that a single, multipurpose FP/MCH visit can save the health system money by using common space, reducing staff costs, and lowering overhead. Broadening skills of personnel helps ease the shortage of health workers (Population Reference Bureau, 2011).
  • Strengthening the contraceptive component of post-abortion care has been shown to increase uptake and reduce unplanned pregnancy and abortions in the future (USAID, 2012).
  • Programmatic evaluations have shown that integrated SRHR and HIV services improve access, increase uptake, and provide better care and increased efficiency (time and resources) (International HIV/AIDs Alliance, 2015).
Standard 4: Providers’ Competencies
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:

  • Build the capacity of health providers to provide SRH information to adolescents
  • Enhance the capacity of law enforcement and health service providers to prevent, respond to and mitigate sexual gender-based violence (SGBV)
  • Build the capacity of health providers to provide adolescent-friendly SRH services through in-service, on-the-job training, mentorship and continuous medical education
  • Support integration of AYSRH training into pre-service curriculum in all medical training institutions
  • Strengthen quality assurance mechanisms through continuous supportive supervision and mentorship at all levels
  • Build the capacity of program managers, planners and service providers on data use for decision-making

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.

Steps:

  1. Assess health facility against the existing standards to see if you have staff already trained in 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:

 TCI’s Hubs are in the process of adapting the WHO SEARO Supervisory/Self-Assessment Checklist.

  1. 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:

  • Essential package for AYFHS
  • Values 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) 
  • Privacy and confidentiality

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

 

 

  1. 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.

  1. 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.
Standard 5: Facility Characteristics
WHO's Definition The health facility has convenient operating hours, a welcoming and clean environment and maintains privacy and confidentiality. It has the equipment, medicines, supplies and technology needed to ensure effective service provision to adolescents.

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
  • Branding (stigma-free): Do you market your facility as a youth-friendly center? 
  • Convenient location (accessible): Is your facility easy to find and 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? 
  • Reception area (privacy): Can clients speak to the receptionist without being overheard?
  • Affordable fees (accessible): Does your facility provide subsidized and/or free services for youth? 
  • Consultation rooms (privacy): Are the consultation areas away from public view?

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.

Standard 6: Equity and Non-Discrimination
WHO's Definition The health facility provides quality services to all adolescents irrespective of their ability to pay, age, sex, marital status, education level, ethnic origin, sexual orientation or other characteristics.

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. 

In addition, TCI’s whole-site orientation approach and approaches for overcoming provider bias (as described in Standard 4: Providers' Competencies) ensures that providers and staff at the facility as a whole are open and non-judgmental in providing services to youth.

Standard 7: Data and Quality Improvement
WHO's Definition The health facility collects, analyses and uses data on service utilization and quality of care, disaggregated by age and sex, to support quality improvement. Health facility staff is supported to participate in continuous quality improvement.

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.

Standard 8: Adolescents’ Participation
WHO's Definition Adolescents are involved in the planning, monitoring and evaluation of health services and in decisions regarding their own care, as well as in certain appropriate aspects of service provision.

Steps:

  1. 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
  1. 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.

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).
  • 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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Tools Related to This Approach

Guidelines and National Standards

India

Kenya

Nigeria

Senegal

Tanzania

Essential Packages of Services
Integration of SRH Services
Assessments
Training Packages

Job Aids

More AYSRH Courses

Making Youth Data Visible

Advocating for Youth-Friendly Cities

Demand Generation for Youth

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