Reproductive Health Programs for Young Adults: Health Facility Programs

Providing young adults with specialized reproductive health information, counseling and services is a relatively recent practice, especially in developing countries. In most countries, family planning clinics have not been seen as relevant to young women, especially unmarried women. Young men have been even less welcome in traditional family planning settings. Adolescents often avoid clinical services that do exist for them, generally out of fear that their wishes for understanding, privacy and confidentiality will not be respected.

Yet reproductive health services are often very much needed by young men and women and are not adequately available elsewhere. Since clinical services are already established and available in many places, they could be adjusted to serve young people well with proper staff training and other selected changes.

Specialized Services for Pregnant Young Women can be made available in clinics or hospitals with adjustments made to meet young women’s needs, enhance their health, and improve birth outcomes. Young women are encouraged to obtain adequate prenatal and postnatal care, with emphasis typically on breastfeeding, infant care and establishment of contraceptive practices to delay a repeat pregnancy.

Specialized Reproductive Health Services for Young People emphasize pregnancy and STD/HIV prevention as well as providing guidance on and treatment of other reproductive health concerns. Program characteristics usually include staff trained to work with young people, reduced fees, drop-in schooling, convenient hours and outreach activities.

Target Audience Identification and Needs Assessment. The prime target group selection should be as specific as possible so that targeted plans can be formulated for recruitment and service provision. In view of the vastly different demographic characteristics, prefer-ences and needs found among groups of young people, assessment should be conducted with representatives of the precise audience targeted for services. Especially important to determine are preferences and needs related to: clinic hours and location, services separated or combined with other age groups, integrated with what other services, provider gender, cost of services, and type of counseling (peer vs. adult; directive vs. non-directive).

Involvement of Youth, Community Members and Family Members. While professionals working with young people generally know key behavioral aspects of their constituency, they may not know what elements of a new program will attract or sustain a particular target group.¹ Thus, young people should be involved in many, if not all, stages of programs, including design, implementation and evaluation.² Community members should also be involved to help ensure program support and acceptance. Particularly important to include are policymakers, health professionals and religious leaders.³ Although there is a lack of conclusive data regarding parental involvement, there is general but not unequivocal agreement that family members’ support should be gained.⁴ While most agree that family member opposition can be a barrier to success, there is also a limit to the roles that adult family members can constructively play in their children’s reproductive health lives due to issues of confidentiality.

Protocols, Guidelines and Standards. Because reproductive health clinics for young adults are relatively new, operational policies governing how providers should serve this group are evolving. To avoid subjective service decisions, which place responsibility on providers who do not always have a positive view regarding these services for youth,⁵ specific and detailed operational policies should be established, resulting in consistent and evenhanded provision of services. To the extent that such protocols are actively supportive of young people’s access, there is a greater potential for recruiting and maintaining a young clientele. Training and orientation, along with appropriate supervision, may be required to assure compliance with guidelines or when introducing a new component for the staff to implement.

Selection, Training and Deployment of Staff. Given reports that service providers in public facilities can be moralistic, giving disciplinary talks to young people seeking reproductive health services,^6,7 and that poor treatment and negative attitudes serve as deterrents to adolescents’ making use of clinical services,⁸ it is clear that staff selection and training (or retraining) are key project components. Most program managers and evaluators consider that a staff trained specifically to serve youth is essential and that this staff should have positive views toward and interests in serving young people.^9,10

What are the key elements of health facility program implementation?

Client Recruitment. It is a common conclusion among administrators and researchers that young adults, especially unmarried ones, do not come to public health services for reproductive health care.⁶ Lack of privacy and bad treatment are frequently cited as reasons, according to studies in Kenya⁶ and Burkina Faso.¹¹ Other reasons include feelings among young people that services are intended only for married people as concluded by researchers in the Philippines.¹⁰ Young people also are often not aware of service locations or what types of services are offered. In an Indonesian study, four in ten adolescents did not know what reproductive health services were available in their area.¹⁰ This is a particular problem among out-of-school youth. Clinics can use diverse communications activities to publicize their services and attract clients. Especially important is word of mouth, as satisfied clients become effective advocates.¹² Personal communications also minimize sensitive mass publicity, as pointed out in an International Planned Parenthood Federation report on adolescent service provision.¹³

Youth-Friendly Environment. Many aspects of the clinic environment have been cited by young people as needing adjustments to make it feel more accepting for them. Foremost among these are privacy and confidentiality. Youth in the Caribbean described an ideal center as one that offers many services, is open in the afternoon and evening, has empathetic, knowledgeable and trustworthy counselors, and doesn’t look like a clinic.¹⁴ A clinic for young clients in Chile has adopted many innovative features, including a staff who wear casual clothes and a noninstitutional-appearing site developed in a cluster of renovated homes.¹⁵

Counseling. While counseling is a highly recommended component of most clinic programs, effective results depend greatly on the quality and extent of the training that counselors receive.⁸ The personal traits of counselors appear to be very important to young clients, including an interest in working with adolescents and an ability to develop respectful relationships.¹⁶ A World Health Organization (WHO) study concludes that there will be minimal impact unless clients are assisted in internalizing the information they receive and owning the resultant protective behaviors.¹⁷ Counseling must also effectively connect young people to services.¹⁶

Appropriate Contraception and Informed Choice. Because of differing availability and circumstances, young people will have to make important decisions about contraceptive use. Counseling should be provided to help them make informed choices, including the option of abstinence.¹⁸ Hormonal methods have been demonstrated as safe for young people, though all methods may not be appropriate for all clients.¹⁹ Barrier methods are good choices, and condoms in particular are widely encouraged because they reduce the risks of contracting STDs, including HIV.²⁰ Other barrier methods, such as the diaphragm, cervical cap and female condom, are effective if used correctly and consistently. They offer some protection against STDs.⁹

STD/HIV Prevention, Diagnosis and Counseling. The idea of addressing broad reproductive health needs in the same facility — especially STD counseling and treatment — is a logical expansion of services to young people. Although many of the behavioral and guidance issues are similar, there has been some hesitancy by staff of family planning centers to screen for and treat STDs. According to a study in Zimbabwe, the issue of condom use for protection against AIDS/STDs was raised by health care providers in only one third of the sessions.²¹ Addressing STDs also remains a problem. A study in Jamaica revealed that only 23 percent of STD patients were offered condoms during their visit.²²

Integrated Approach. Efforts are being made to combine services for adolescents in the same facility. WHO argues that to be effective programs must have multiple interventions to meet the diverse needs of youth.¹⁶ Combining preventive care, especially contraceptives, with prenatal, postnatal and abortion care is a comprehensive model for reproductive health, resulting in both contraceptive and maternal care benefits. Attention to the nutritional needs of young people can also be accomplished within the health care setting.

Affordability. Costs of reproductive health services, if they are to be covered by young adults themselves, must be affordable. If costs are too high, they constitute a barrier to clinic use.¹³ Although affordability is important, its translation into a specific fee varies according to the country and the group targeted for services.⁸ For example, researchers in one study found that even if adolescents could not afford very much, most would rather pay something because they tend to view free services as being of poor quality.⁶

References

1. Senderowitz, J. (1995). "Lessons Learned: Ten Tips for Meeting the Needs of Young Adults." Population Reports Series J (41).
2. Koontz, S.L. and S.R. Conly (1994). "Youth at Risk: Meeting the Sexual Health Needs of Adolescents." Population Policy Information Kit #9. Washington DC: Population Action International.
3. International Planned Parenthood Federation (IPPF). 1994. Understanding Adolescents: An IPPF Report on Young People’s Sexual and Reproductive Health Needs. London: IPPF.
4. Pathfinder International. 1993. "Adolescent Reproductive Health/Family Planning Programs in Sub-Saharan Africa." (Paper presented by Pathfinder International at USAID).
5. Senderowitz, J. 1995. Thematic Evaluation: Reproductive Health/Family Planning IEC and Services for Adolescents (Case Study: Jamaica and Antigua). New York: UNFPA.
6. Marie Stopes International. 1995. "A Cross-Cultural Study of Adolescents to Family Planning and Reproductive Health Education and Services." (Final Report to the World Bank).
7. Senderowitz, J. 1995. "Adolescent Health: Reassessing the Passage to Adulthood." World Bank Discussion Papers No. 272. Washington DC: World Bank.
8. UNICEF. 1996. Youth Health – For a Change: A UNICEF Notebook on Programming for Young People’s Health and Development. (Working Draft I.)
9. McCauley, A.P. and C. Salter. 1995. Meeting the Needs of Young Adults. Population Reports Series J (41).
10. WHO. 1995. Provision of Adolescent Reproductive Health Services to Adolescents in Indonesia, Nigeria and the Philippines. (Draft).
11. Gorgen, R., B. Maier and H.J. Diesfeld. 1993. "Problems Related to Schoolgirl Pregnancies in Burkina Faso." Studies in Family Planning 24(5).
12. Herz, E.J., L.M. Olson and J.S. Reiz. 1988. Family Planning for Teens: Strategies for Improving Outreach and Service Delivery in Public Helath Settings. Public Health Reports 27 (2).
13. IPPF. 1988. "Adolescent Fertility and FPA Service Provision." (A Report of a Joint Meeting of the International Programme Committee and Programme Committee of the East and Southeast Asia and Ocean Region, Bangkok, Thailand, 5-6 December 1987.)
14. Kurz, K.M., C. Johnson-Welch, E. LeFranc and P. Hamilton (1995). Adolescent Fertility and Reproductive Health: A Needs Assessment in the English Speaking Caribbean for the Pew Charitable Trusts. Washington DC: ICRW.
15. Corona D., P. Canessa, and C. Benbow-Ross. 1995. Adolescent Reproductive Health Thematic Evaluation: Country Case Study Report – Chile. UNFPA. (Draft.)
16. WHO/UNIFPA/UNICEF Study Group on Programm-ing for Adolescent Health. 1995. "Programming for Adolescent Health." (Discussion paper).
17. Wastell, C. 1995. "Effectiveness of Counseling in Adolescence." (Prepared for the WHO/ UNFPA/UNICEF Study Group on Programming for Adolescent Health).
18. Waszak, C.S. 1993. Quality Contraceptive Services for Adolescents: Focus on Interpersonal Aspects of Client Care. Fertility Control Reviews. 2(3).
19. Contraceptive Technology Update. 1988. "Finding the Right Contraceptive for Young Teens Challenges Clinicians." Contraceptive Technology Update 9 (11).
20. Brabin, L. 1995. "Preventive and Curative Care for Adolescents: The Role of the Health Sector." (Prepared for the WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health).
21. Kim, Y.M. and C. Marangwanda. 1996. Attending Young Clients, Quality of Counseling in Zimbabwe. Baltimore, MD: Johns Hopkins Center for Communication Programs.
22. Bryce J., et al. 1994. "Quality of Sexually Transmitted Disease Services in Jamaica: Evaluation of a Clinic-based Approach." Bulletin of the World Health Organization. 72 (2): 239-247.