Inconvenient hours or location, unfriendly staff and lack of privacy are among reasons many young adults give for not using reproductive health clinics.
A campaign in South Africa is trying to address such concerns through a certification process in which clinics that meet certain standards that help youth will receive recognition.
Plans for the project draw on such models as the "gold star" campaign used in Egypt to indicate family planning clinics that meet national standards for good service quality. The Egyptian campaign uses television messages and posters to promote the gold star clinics. The South African campaign plans to use the stars to help adolescents identify clinics that might be more friendly to their needs.
"We need accessible clinics with nonjudgmental, friendly staff and reduced waiting times," says Kim Dickson-Tetteh, who is coordinating the initiative through the Reproductive Health Research Unit (RHRU), University of the Witwatersrand in Soweto, and the South Africa Department of Health. The campaign seeks to make health-care services more accessible and acceptable to adolescents, to establish national standards and criteria for adolescent health care in clinics throughout the country, and to help health-care providers improve their delivery of adolescent-friendly services. Called the National Adolescent-Friendly Clinic Initiative (NAFCI), it is funded by the Henry J. Kaiser Family Foundation and is part of a public education program called Initiative Lovelife.
Adolescents have indicated what they would like to have in clinic services. A study by the Washington-based International Center for Research on Women, based on research with adolescents in Africa, Asia, Latin America and the Caribbean, recommends that reproductive health services for youth be private, confidential, affordable, accessible and staffed with sensitive providers.1 At a youth information center set up by the Planned Parenthood Association of South Africa, youth said the most important factors determining their choice of a clinic were staff attitudes, location and atmosphere, contraceptive methods available and clinic hours, in that order.2
"The circumstances vary extensively regarding what kinds of clinical services will best serve youth," says Dr. Cynthia Waszak of FHI, who has evaluated adolescent programs throughout the world. "Sometimes youth want service centers just for youth. Other times they want them integrated into existing clinics. The most important thing is to ask youth and providers in a particular community what they want and what will work best for them."
In many countries, the attitudes of providers have discouraged even married adolescents. One study of services for married teenage women found that providers in some countries refuse to provide services until the young wives have given birth.3 In countries where women typically marry in their teenage years, another study found that it is often difficult for teenage married women to reach clinics, emphasizing the need for outreach workers who can assist newlyweds.4
FOCUS on Young Adults, implemented by the U.S.-based Pathfinder International, has developed workbooks to score clinics on the quality of their services to youth. The workbooks examine four areas: the facility itself, including operating hours, location and privacy; staff performance, including respect shown to clients, confidentiality and adequate time for interaction; administrative procedures, such as whether fees are affordable and whether drop-in clients are welcome; and how youth perceive the clinic's services.5
"Evaluation is still very limited on how effective such projects [to attract young adults] are -- or can be," reports Judith Senderowitz, a consultant for the FOCUS project. "Furthermore, most demonstration activities have looked mainly at the overall effects of the program design and, therefore, cannot attribute results to specific youth-friendly components."6
The FOCUS review identified efforts to promote youth-friendly efforts in prenatal, postpartum and postabortion programs, primarily in hospitals, in Brazil, Chile, Ghana, Kenya, Mexico and Nigeria. In Brazil, when a hospital offered specific hours, counseling, education and contraceptives through outpatient services to adolescents, 50 percent of the young women patients returned after birth or abortion for these services.7
Innovative services for youth have been developed in general clinical settings in many other countries. In Zambia, for example, the Lusaka Urban Youth-Friendly Health Services project used participatory needs assessments and learning exercises to involve community leaders and parents. The project provided education on contraception and prenatal care at seven clinics, two of which also had peer educators. The number of youth using the clinics doubled as a result of the project, with significantly more nonpregnant teenage girls seeking counseling and contraceptive services.8
The South Africa certification program has developed what it calls an "essential service package of adolescent-friendly services" drawing upon World Health Organization recommendations for primary health care services. Standards have been developed based on research of what adolescents say they want in clinical services. The standards include policies and processes that support adolescents' rights, a physical environment conducive to the provision of adolescent-friendly services, and the provision of psychosocial and physical assessments of youth.
An innovative aspect of the South Africa effort is that the clinics themselves determine how to make their services more youth-friendly. "If the clinic staff members find that they do not meet the standards, then they determine what they should do to move in that direction -- such as reducing waiting time or training staff to provide adolescent-friendly services," says Dickson-Tetteh of RHRU.
Involvement in the steps toward certification means the staff understand what they need to do and become more invested in the outcome. "Using this self-assessment approach gives the clinics the opportunity to look at themselves and their operations," says FHI's Tara Nutley, who participated in a meeting of international experts who helped plan the project. "It is a valuable part of the process."
While helping clinics to be friendly to youth is important, some analysts emphasize that clinic-based services alone cannot serve the needs of all youth. "We have to design services that reach out into the community, to where the youth are. Otherwise, many adolescents will never get the services they need," says Nutley.
Developing community-based programs that provide such services as contraceptives and counseling is challenging, however. Annabel Erulkar and colleagues at the New York-based Population Council recently evaluated 14 community-based youth centers in Kenya, Zimbabwe and Ghana. Centers typically offered recreation, vocational education or a library along with reproductive health services.
By offering other activities, centers attempt to be more attractive to youth. However, youth centers are often stigmatized by the community and youth themselves. "Many youth, especially girls, do not want to be associated with family planning organizations because it suggests sexual activity or because young people brand them as places for those with sexually transmitted diseases," concludes an evaluation. Those who do visit the centers are older youth, averaging 21 years of age in Zimbabwe. In Kenya, about nine of every 10 clients were over age 20 with a quarter of them older than the upper limit of 24.
The evaluations also found that staff are highly knowledgeable but are often judgmental. Asked how he would respond to an unmarried girl seeking contraception, a Kenyan provider said, "I would reverse her mind and tell her not to have sex," an attitude that would discourage sexually active young adults from using contraception.9
-- William R. Finger
References
- Weiss E, Whelan D, Gupta GR. Vulnerability and Opportunity: Adolescents and HIV/AIDS in the Developing World. Washington: International Center for Research on Women, 1996.
- Transgrud R. Adolescent Reproductive Health in East and South Africa: Building Experience, Four Case Studies -- A Report Prepared for the Regional Adolescent Reproductive Health Network, USAID, REDO/ESA. Nairobi: Family Care International, 1998.
- Mensch BS, Bruce J, Greene ME. The Unchartered Passage: Girls' Adolescence in the Developing World. New York: The Population Council, 1998.
- Alauddin M, MacLaren L. Reaching Newlywed and Married Adolescents. Washington: FOCUS on Young Adults, 1999.
- Nelson K, MacLaren L, Magnami R. Assessing and Planning for Youth-Friendly Reproductive Health Services. Washington: FOCUS on Young Adults, 2000.
- Senderowitz J. Making Reproductive Health Services Youth Friendly. Washington: FOCUS on Young Adults, 1999.
- Senderowitz.
- Haambayi RZ, Weiss LA. Young Adult Reproductive Health in Zambia: A Review of Studies and Programs. Washington: FOCUS on Young Adults, 1999.
- Erulkar AS, Mensch BS. Youth Centers in Kenya: Evaluation of the Family Planning Association of Kenya Programme. Nairobi: Population Council, 1997; Glover EK, Erulkar AS, Nerquaye-Tetteh J. Youth Centers in Ghana: Assessment of the Planned Parenthood Association of Ghana Programme. Nairobi: Population Council, 1998; Phiri A, Erulkar AS. A Situation Analysis of the Zimbabwe National Family Planning Council's Youth Centers. Nairobi: Population Council, 1997.
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