AYSRH ToolkitDelivering Services for Youth
Adolescent & Youth-Friendly Health Services
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:
- Standard 1: Adolescents’ health literacy (Comprehensive Sexual Education)
- Standard 2: Community support (Community Gatekeepers)
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.
- Familiarize yourself with national guidelines and packages of essential services for young people at different levels of the health system.
- Partner with young people residing in urban environments to define the package of services that would best fit their needs.
- Discuss and decide upon the package of services that is feasible to provide, based on considerations of funding, facilities and human resources.
- Ensure that health providers possess the skills, competencies and attitudes to provide all health services on offer.
- 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:
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 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’s Hubs are in the process of adapting the WHO SEARO Supervisory/Self-Assessment Checklist.
- 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 TCI’s Francophone West Africa Hub’s agenda (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.
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|
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.|
- 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
- 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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- Include youth as experts in health provider trainings; make an extra effort to include representatives from sub-populations such as younger adolescents, married youth, etc.
- Involve youth in monitoring, evaluation, and accountability mechanisms aimed at ensuring compliance with standards for health providers.
- WHO SEARO’s Supervisory/Self-Assessment Checklist enables 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 age-disaggregate data on youth to inform the content of provider trainings.
- 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, youth 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 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 to ensure 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 of interest to youth.
- 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.
- When youth 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 youth can play in health.
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
Essential Packages of Services
- Essential Packages Manual: SRHR Programmes for Young People, Rutgers
- Planning and Implementing an Essential Package of Sexual and Reproductive Health Services: Guidance for Integrating Family Planning and STI/RTI with other Reproductive Health and Primary Health Services, UNFPA
- Integrated Package of Essential Services, IPPF
Integration of SRH Services
- Preconception care: Maximizing the gains for maternal and child health, World Health Organization
- Integrating Family Planning and Maternal and Child Health: Saving Lives, Money and Time, Population Reference Bureau
- Meeting the Sexual and Reproductive Health Needs of Young Married Women and First-time Parents Toolkit, Pathfinder International, E2A Project
- My First Baby: Guide for Adolescent Girls, Save the Children
- A Guide for Developing Family Planning Messages for Women in the First Year Postpartum, ACCESS-FP
- Postabortion Family Planning: Strengthening the family planning component of postabortion care, USAID
- Postabortion Family Planning: Addressing the Cycle of Repeat Unintended Pregnancy and Abortion, Guttmacher Institute
- Assessment of Youth-Friendly Postabortion Care Services: A Global Tool for Assessing and Improving Postabortion Care for Youth, Pathfinder International
- Youth Friendly Postabortion Care Supplemental Training Module, Postabortion Care Consortium
- Contraceptive Guide for PAC Service: Pocket Reference for Clinicians, VSI
- Postabortion Care Website (Resources in English | French)
- Sexual and reproductive health and rights, and HIV 101 workshop guide: A guide to facilitating a workshop on linking up HIV and sexual and reproductive health and rights with young key populations, International HIV/AIDS Alliance
- Sexual and Reproductive Health and HIV/AIDS: A Framework for Priority Linkages, WHO
- Family Planning, HIV & STIs, and Gender Matrix, International Youth Foundation
- Models of integrated care for young people from key populations in Uganda, International HIV/AIDS Alliance
- REAL Fathers Mentor Curriculum: Using Mentors to Increase Positive Fatherhood Practices and Non-violent Couple Communication with Newly Married Young Men, IRH, Save the Children
- CHARM: Counseling Husbands to Achieve Reproductive Health and Marital Equity – Training Manual, Center on Gender Equity and Health
- Provide: Strengthening Youth-friendly Services and accompanying self-assessment tool, IPPF
- Supervisory/Self-Assessment Checklist for Adolescent Friendly Health Services, WHO SEARO
- Quality Assessment Guidebook: A Guide to Assessing Health Services for Adolescent Clients, WHO
- A Tool to Assess the Gender Sensitivity of a Health Facility, Health Policy Project
- 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
- Defining and Advancing Gender-Competent Family Planning Service Providers, HRH2030
- 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