Adolescent & Youth Sexual & Reproductive Health Toolkit: Services & Supply
Adolescent & Youth-Friendly Services
Adolescents and youth face a wide range of barriers in accessing high-quality sexual and reproductive health (SRH) services. These include:
- Structural barriers, such as laws and policies requiring parental or partner consent, distance from facilities, costs of services and/or transportation, long wait times for services, inconvenient hours, lack of necessary commodities at health facilities, and lack of privacy and confidentiality.
- Sociocultural barriers, such as restrictive norms and stigma around adolescent and youth sexuality; inequitable or harmful gender norms; and discrimination and judgment of adolescents by communities, families, partners, and providers.
- Individual barriers, such as young people’s limited or incorrect knowledge of SRH, including myths and misconceptions around contraception; limited self-efficacy and individual agency; limited ability to navigate internalized social and gender norms; and limited information about what SRH services are available and where to seek services.
Although adolescents and youth are a heterogeneous group, they share two common characteristics in seeking health services: They want to be treated with respect and to be sure that their confidentiality is protected (WHO, 2002).
Adolescent and youth-friendly services (AYFS) (also called youth-friendly services, YFS) are designed to address these barriers in order to attract and retain young people for services (Senderowitz, 1999). In addition, there is growing recognition of the need to make existing health services youth-friendly instead of having stand-alone or separate-space models for delivery contraceptive services to adolescents and youth (USAID, 2015).
In collaboration with partner organizations and national stakeholders, World Health Organization (WHO) developed the following Global standards to improve quality of health-care services for adolescents.
- Standard 1: Adolescents’ health literacy
- Standard 2: Community support
- Standard 3: Appropriate package of services
- Standard 4: Providers’ competencies
- Standard 5: Facility characteristics
- Standard 6: Equity and non-discrimination
- Standard 7: Data and quality improvement
- Standard 8: Adolescents’ participation
These standards help to minimize variability and ensure a minimal required level of quality to protect adolescents’ rights in health care (Nair et al., 2015). The TCI AYSRH toolkit includes interventions or approaches that address each of these standards. As a result, this approach page focuses primarily on guidance for training providers, making facility improvements to better attract and serve adolescents and youth, and facility-level data considerations and requirements.
What Are the Benefits?
- Facilitates young people’s access to and satisfaction with services
- Gives higher quality SRH services to young people
- Empowers health providers to be advocates for young people
- Encourages future health-seeking behavior among young people
How to Implement?
These steps are informed by USAID’s High Impact Practice brief on Adolescent-friendly contraceptive services: mainstreaming adolescent-friendly elements into existing contraceptive services.
Ensure institutional standards for youth-friendly service align with international standards
Most health ministries and service-providing institutions have articulated the core competencies that health providers need in order to provide youth-friendly SRH services, and included them policies, strategies and/or national standards. These important reference documents ensure awareness and standardization across programs, service delivery points, and providers.
|Example: Ministry of Health, Kenya|
|The National Adolescent Sexual and Reproductive Health Policy (2015) articulates the following priority actions related to enhancing the skills of health professionals:
If such standards do not exist and must be developed, young people or youth organizations are crucial allies in ensuring that they are youth-responsive and context-specific. The World Health Organization (WHO)’s Core Competencies in Adolescent Health and Development for Primary Care Providers includes:
|Basic concepts in adolescent health and development, and effective communication||
|Laws, policies and quality standards||
|Clinical care of adolescents with specific conditions||
In addition to these general competencies, WHO has defined an adolescent-friendly provider in its Adolescent Friendly Health Services: An Agenda for Change as one who:
- Possesses technically competent in adolescent-specific areas, and offers health promotion, prevention, treatment and care relevant to each client’s maturation and social circumstances;
- Has interpersonal and communication skills;
- Is motivated and supported;
- Is non-judgmental and considerate, easy to relate to and trustworthy;
- Devotes adequate time to clients or patients;
- Acts in the best interests of their clients;
- Treats all clients with equal care and respect; and
- Provides information and support to enable each adolescent to make the right free choices for his or her unique needs.
|Practical examples of how health providers can be youth-friendly|
Assess your facility against existing standards
Perception is just as important as reality for young people. If your facility is not seen to be youth-friendly amount the young people in the catchment area, then they will not come. Management, providers, and other staff must all work to promote the perception that services are meant for young people and that they meet existing standards.
There are a number of tools that can be used to assess the extent to which a facility is offering adolescent and youth-friendly services. Here are some examples:
- 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
These assessments assess the facility and services provided against the global 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 for young people, it won’t matter what the facility looks like. As a result, removing or reducing user fees or providing vouchers and cash transfers to adolescents and young people may be required.
Solicit feedback from adolescents and youth who visit your facility
As part of the assessment, engage adolescents and youth. There’s no better way to ensure whether or not young people find your facility to be youth-friendly than engaging them in the process of defining what it would look like. It can be as simple as holding focus groups and running through the different criteria that matter to them when accessing facility-based services.
Ask young clients:
- How they found out about your facility
- If they would refer the service to their peers
- If they felt respected
- If their privacy was protected
- If they received the services they came for or were denied on the basis of age, marital status, or other markers
Setting up a facility advisory committee that includes some young clients would enable regular quality improvement for the facility, and ensure that young people can hold the facility accountable. Toolkits like IPPF’s Provide: Self-Assessment Tool for Youth-friendly Services can also support ongoing self-monitoring. Using monitoring tools and disaggregated data on client age, sex, parity and service type, facilities can be very responsive to the needs and realities of the young people in their vicinity. It is important to act on the results and recommendations coming from these feedback mechanisms as well as those from the assessments. Young clients should be able to see that their opinions and needs and listened to and acted upon at the facility.
Programmatic example: Young researchers determine youth-friendliness in Malawi and Bangladesh
Rutgers and the International Planned Parenthood Federation (IPPF) trained young people as researchers in Malawi and Bangladesh. A two-week intensive training included topics such as sexual and reproductive health, qualitative research methodologies and data analysis. Over an extended period, the young researchers were engaged in interviews and focus groups with peers who had accessed services at health clinics (both urban and rural) to determine the extent to which young people’s expectations were met by each clinic. Results from Malawi indicated that young people were drawn to facilities depending upon how confidential they were, the availability of services, friendliness of providers and the cost of services.
Develop and deliver a training curriculum
Evidence indicates that training for health providers should include not only information about adolescent development and health but also their rights (Evidence to Action, 2014). Trainings should also include information on the social determinants of health; in urban environments, trainings should include information on how to reach and provide services to key populations. Integrate “values clarification and attitude transformation” components into health provider trainings, encouraging reflection on the socio-cultural biases that impact their work. Promote doing good, not just doing no harm; and support, rather than blame, health providers as they implement new practices.
|Illustrative provider training topics|
|Health service providers should receive training on but not limited to:
In the absence of pre-service training on adolescent SRH, training can take place as part of on-the-job training or whole site orientation. See this agenda for an example of six training sessions that can be included as a whole site orientation training schedule. Include administrative, cleaning and laboratory staff in trainings on youth-friendly services to ensure that young clients’ interactions with all staff members at service delivery points are positive.
NURHI Pilots 3 New Approaches to Overcoming Provider Biases
In an effort to help providers overcome their biases related to family planning services for young people, the Nigerian Urban Reproductive Health Initiative (NURHI) has piloted three approaches: the fishbowl approach, a values clarification exercise and videos.
The fishbowl approach works by facilitating a roundtable discussion with providers and clients. The discussion starts with the clients sitting in an inside circle, with providers sitting around an outside circle. During the dialogue, only participants in the inner circle are allowed to talk. They are asked to share their experiences, including how they were treated by a provider, if they got the services they wanted, or the consequences they faced for not receiving the requested services. Then, the clients and the providers switch places, giving the providers a chance to speak about their challenges, including being overworked, having to see too many clients, or not receiving pay for several months. These dialogues have been an eye-opening experience for both clients and providers and have helped dispel misconceptions that providers are inhumane and show providers that there can be dire consequences for clients who do not receive the appropriate care.
The values clarification exercise works by having people examine their own perceptions. NURHI asks providers to agree or disagree with statements about their values and then discuss why they agree or disagree. After a group discussion, they link what people say back to the National Family Planning / Reproductive Health Service Protocols to determine the appropriate recommendations for service provision.
Finally, NURHI has developed two videos to depict client-provider interactions with young people. Given responses shared by young people themselves, the videos show interactions with a supportive and an unsupportive provider (these terms are chosen carefully, as not to dissuade providers from using the videos by deeming them as friendly or unfriendly). So far, these videos have been received positively because they allow the provider to identify and reflect on their behaviors on their own terms.
Put in place systems and resources for ongoing support for health providers
Provide ongoing training and support. One-off trainings are not effective at improving the quality of or demand for youth-friendly SRH services. Ongoing reinforcement—including supportive supervision, job aids, and mentoring—is required to ensure that providers can meet the needs of youth, and are encouraged to be advocates for young people’s SRHR.
- Provide job aids for health providers that are easy to access during or between consultations.
- Establish case management support groups for health providers to discuss cases and best practices in SRH provision to young people.
- Support a mentorship scheme in place for health providers to learn from one another.
- Identify “early adopters” of youth-friendly services and make them champions of the cause.
This video demonstrates effective ways to talk to young women about long-acting reversible contraceptive methods (LARCs). Also available is a video discussion guide to help program managers or health facility senior staff facilitate deeper dives into the video’s key messages, including provider bias.
HC3 | Talking about LARCs with Young Clients: A Video for Providers (English) HC3 | Talking about LARCs with Young Clients: A Video for Providers (French)
Establish monitoring, evaluation and accountability systems
Systems should be in place to collect and analyze data on health providers’ competencies related to adolescent SRH as well as service delivery statistics on the services sought by adolescents and youth, disaggregated by age, sex, parity and service type. Hold regular meetings with staff to review services statistics. Identify data quality issues in terms of gaps in recordkeeping as well as analyze what the data on adolescents and youth tells you given the population in your catchment area. Are adolescents and youth represented in the data? What segments are missing?
Develop partnerships with youth-led organizations that can help monitor youth-friendliness of services (both of the provider and facility) using mystery client, focus group, or other data collection methodologies. These data should be discussed regularly with health providers to ensure quality improvement.
Additionally, program implementers should develop systems for situations wherein young people’s sexual and reproductive rights (SRR) have been violated by a health provider. Health providers should remain accountable to young people for the delivery of rights-based SRH services.
What Is the Evidence?
- A project on mainstreaming youth-friendly services in Mozambique and Tanzania demonstrated an increase in new contraceptive users among 10-24 year olds, and a significant number of young clients reported satisfaction with the services and being treated with respect by the service providers (Pathfinder International, 2017).
- In Nigeria, nurse/midwives trained by the Nigeria Urban Reproductive Health Initiative (NURHI) had significantly lower age bias (refusing to offer a method to a person age 15 or older) for male condoms, pills, EC, injectables, and IUDs compared to those nurse/midwives who received non-NURHI in-service family planning training and those who did not receive any training at all (NURHI, 2017).
- Evidence from urban Senegal suggests that male providers, nurses, and older staff may be more likely to apply restrictions to contraceptive access based on clients’ age and/or marital status (Sidze et al., 2014).
- A literature review on young people’s perspectives on health care revealed that there are eight indicators which are central to young people’s positive experience of care: accessibility of health care; staff attitude; communication; medical competency; guideline-driven care; age appropriate environments; youth involvement in health care; and health outcomes (Ambresin et al., 2013). Another literature review on evidence for improving adolescent access to and use of SRH services highlights that the most effective interventions in increasing adolescents’ and young people’s access to services is to ensure that, other than quality clinical services, sexuality and life skills education, and linkages with educational and economic opportunities and supportive adults are in place (Denno et al., 2015).
- Evaluations of young people’s access to services shows that competent health providers alone is not enough to increase young people’s access to SRH services (Chandra-Mouli et al., 2015; Dick et al., 2006). Approaches to scaling up services should use four complementary approaches:
- Providers are trained and supported to be nonjudgmental and friendly to adolescent clients
- Health facilities are welcoming and appealing
- Communication and outreach activities inform adolescents about services and encourage them to make use of services
- Community members are supportive of the importance of providing health services to adolescents
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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’re reviewing the youth-friendliness of your service delivery point by going through WHO SEARO’s Supervisory/Self-Assessment Checklist for Adolescent Friendly Health Services or IPPF’s Provide, ask some of your young clients to fill it out on their own and compare your answers.
- Include young people as experts in health provider trainings.
- Involve young people in monitoring, evaluation, and accountability mechanisms aimed at ensuring compliance with standards for health providers.
- Toolkits like IPPF’s Provide can also enable ongoing self-monitoring of the facilities. Combined with disaggregated data on age, sex, and service type, facilities can be very responsive to the needs and realities of the young people in their vicinity.
- Use data on youth to inform the content of trainings for providers, including data on key youth populations.
- Ensure that health providers are aware of the most salient data on youth SRH in the context.
- There is no one-size-fits-all-approach, which is why it is important to reach adolescents with sexual and reproductive health services at different stages of need. Often, young people have more concerns on the social and mental aspects of sexual and reproductive health, rather than clinical services. Therefore, partnering with specialized services for referrals, based on an assessment of local needs, is important.
- Link with training institutions that can provide ongoing and refresher trainings for staff.
- Making any facility youth-friendly may require an initial injection of financial resources, including to make adjustments to clinic layout (construction and/or furniture) to respect young clients’ privacy.
- There may be forces outside of the control of the facility that mean that it cannot meet all standards of youth-friendliness. For example, supply chain blockages may make it impossible to procure adequate commodities.
- Monitoring and evaluation often requires (human) resources and expertise that some facilities don’t have, which means that there is no feedback mechanism to check the youth-friendliness of the facility.
- Norms related to gender and sexuality form from a very young age. Changing these norms takes generations. Health provider trainings should include reflection on these norms and the adverse health consequences that they have, particularly for young women. Trainers should engage health providers continually in critical reflection and participatory learning. Youth-adult partnership may be another way that adult health providers can learn from young people about life experiences that reflect the harmful effects of patriarchy.
- When young people are placed in a position of commenting on adult health providers’ competencies, there may be backlash. Health provider training should take this into consideration and raise awareness of the leadership role that young people can play in health, as well as how to enter into equal partnerships with young people.
Tools Related to This Approach
Guidelines and National Standards
- 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
- 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
- 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