Making Reproductive Health Services Youth Friendly

Senderowitz, 1997

In most developing country settings, young unmarried adults tend not to go to health facilities—particularly public clinics—for their reproductive health needs. The history of family planning service delivery explains some of this reluctance. Traditionally, maternal and child health (MCH) and family planning services were designed to serve the childbearing and childspacing needs of married women. ^{21, 23, 24, 27, 28, 34}

In some places, because of cultural sensitivities, services are withheld from young people, especially if they are unmarried, and sometimes even from married women before they become pregnant for the first time. Furthermore, few providers have had any specialized training or gained much experience in meeting the special reproductive health needs of adolescents. Many providers, therefore, remain ill-equipped to serve this group.

 Why do young people have difficulty using reproductive health services?

A number of factors are likely to make adolescents and young people uncomfortable:

• Unmarried young people often think that reproductive health services are not intended for them.⁴²

• They are often embarrassed at being seen in a reproductive health facility.^{11, 29}

• They are likely to be concerned about a lack of privacy and confidentiality, or afraid that their parents might find out about their visit.^{7, 13, 15, 23, 24, 29, 30, 33, 37}

• They are afraid of medical procedures, especially pelvic exams.³⁷

• They might be ashamed of having experienced coercive or abusive sex.³¹

• They find the clinic staff hostile.^{27, 29, 30, 32}

There are a number of other frequent obstacles standing in the way of young people:

• Many adolescents are unaware of the risk of pregnancy. They are also unfamiliar with STD symptoms and don’t know when to seek services.

• They don’t know where reproductive health services are located, or they are unfamiliar with the kinds of services offered.^{5, 11, 36, 37, 42}

• The health facilities they might go to are not open at convenient hours.^{27, 29, 32}

• There is no transportation to an existing clinic site.^{26, 32, 37}

• The cost of services is beyond their means.^{11, 16, 26, 27, 37}

What would youth-friendly services look like?

Concerned program professionals are now beginning to address many of the difficulties and obstacles confronting young people. Some clinics now serve young women before their first birth, or welcome young men as clients. There is also a trend toward providing a broader array of reproductive health services. Clinics that have tailored their service provision to attract young people and meet their special reproductive health needs can be identified by one or many of the following characteristics:

Provider Characteristics

• The staff have been specially trained to work with young adults.^{1, 11, 16, 25, 36, 42}

• Staff are trained to respect young people and their needs.³⁷

• Staff acknowledge the central importance to adolescents of privacy and confidentiality.^{2, 4, 11, 24, 40}

• Clinic managers make sure there is extra time allowed for counselors or medical staff to discuss young people’s special issues.²¹

Health Facility Characteristics

• Separate space or special times are set aside for young adult clients.^{3, 14, 38}

• Clinics are open at times convenient for young adults to attend, such as late afternoons, evenings, and weekends.^{17, 22, 23, 25, 30, 39}

• Facilities are conveniently located.^{17, 22, 29, 37}

• There is adequate space, and it is arranged so that young people’s privacy is protected.

• Clinic surroundings are comfortable, as "unmedical" as possible, and made appealing for young people.⁹

Program Design Characteristics

• Drop-in clients are welcomed.^{6, 16, 30, 39} 

• Overcrowding is avoided and waiting times are short.^{21, 37}

• Service charges are as low as possible, so that young people can afford them.¹⁴

• Boys and young men are encouraged to attend, and special male services are offered.^{10, 37}

• Audio-visual and print material dealing with issues relevant to young adults are offered in waiting areas.

• The availability of special programs for young people is widely publicized in such places as schools, offices, factories, and recreational and other community settings. Such open publicity often serves to increase young people’s comfort level with a program.^{11, 14, 25, 29, 30, 37}

Some characteristics are less common and more experimental in nature:

• Peer counselors work with clients.¹⁹

• A physical examination might be delayed for up to six months after the pill has been prescribed.⁸

• Informal and formal group discussions are held.^{14, 37}

• The health facility provides a wide range of reproductive health services such as STD and HIV prevention, STD diagnosis and treatment, nutritional services, sexual abuse counseling, prenatal and postpartum care, and abortion services.^{3, 15, 18, 20}

• Peers or adult professionals working in outreach programs promote information and some commodities (such as contraceptives, iron tablets, vitamin supplements).

 What kind of services do young people want?

The importance of each characteristic varies with the type of client and the nature of the service being sought. Teenagers do not consistently rank special hours or special clinic times set aside for them as important.⁴³ Yet even when special hours are not high on the list, as in one US study, teenagers who enrolled as virgins or within two months of first intercourse were more likely to go to a clinic with special teen hours than to other clinics.⁴³ In Jamaica, the existence of a special evening clinic was found to attract many first-time clients.³⁸ It has been suggested that separate services may be more important in the case of high-risk youth who need to overcome their resistance to using traditional health care systems.³

Because young people are not everywhere the same, it is important to find out about service preferences in different cultural settings. Here are examples of what some selected groups of young people in various settings have said they would ideally like:

• In a needs assessment study conducted in six English-speaking Caribbean countries, young people said the ideal center would offer many different services, would be open afternoons and evenings, would be staffed by empathetic, knowledgeable, and trustworthy advisers, and would not look like a clinic.²³

• In a Youth Information Centre set up experimentally by the Planned Parenthood Association of South Africa, young people said the most important factors determining their choice of a clinic were staff attitudes (95%), the surroundings (location, decor, and atmosphere—89%), the contraceptive methods available (85%), and operating hours (81%).³⁵

• After research with adolescents in Africa, Asia, Latin America and the Caribbean, the International Center for Research on Women recommends that reproductive health services be private, confidential, affordable, accessible, and staffed with sensitive service providers.⁴¹

• In a US study of how adolescents made decisions about where to seek general health care, 14 of 15 top-ranked items pertain to providers, and six of these concern interpersonal factors such as honesty, respect, and confidentiality. Four of the top characteristics pertain to infection control because of adolescent concerns about HIV transmission.¹²

Bibliography

1 Abdool KQ, Abdool KS, Preston-White E. Teenagers Seeking Condoms at Family Planning Services. Part II. A Provider's Perspective. South African Medical Journal 82:360-3 (1992).

2 Anonymous. Providing OCs without exam may be better for some teens. Contraceptive Technology Update 11(11). 1990.

3 Barker G. Iniciativa de Evaluación de Programas de Salud Reproductiva de Adolescentes: Confrontando Nuevos Desáfios para el Siglo 21. Documento de discussión preparado para la reunión de planeamiento en la Ciudad de Mexico. 20-21 marzo 1994.

4 Barker G, Fontes M. Review and Analysis of International Experience with Programs Targeted on At-Risk Youth. Unpublished report for the Government of Colombia, The World Bank, 1996.

5 Brabin L. Preventative and Curative Care for Adolescents: The Role of the Health Sector (excerpts). Prepared for WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health. 28 November-4 December 1995.

6 Bryce J, Vernon A, Brathwaite AR, et al. Quality of Sexually Transmitted Disease Services in Jamaica: Evaluation of a Clinic-Based Approach. Bulletin of the World Health Organization 72(2):239-247 (1994).

7 Chamie M, Eisman S, Forrest JD, et al. Factors Affecting Adolescents' Use of Family Planning Clinics. Family Planning Perspectives 14(3): (1982).

8 Cheng T, Savageau J, Sattler A, et al. Confidentiality in Health Care—A survey of Knowledge, Perceptions, and Attitudes among High School Students. Journal of the American Medical Association. 269(11). 1993.

9 Corona E, Canessa P, Benbow-Ross C. Adolescent Reproductive Health Thematic Evaluation. Country Case Study Report—Chile. (Draft) UNFPA, 1995.

10 Dryfoos JG. Putting Boys in the Picture: A Review of Programs to Promote Sexual Responsibility among Young Males. Network Publications. ETR Associates, 1988.

11 Ferrando D, Meikle C. Benavente J. Adolescent Health Services Project Evaluation at the Fundación San Gabriel (NCA/BOL 017-3) in La Paz, Bolivia. (Draft report) 1995.

12 Ginsburg KR, Slap GG, Cnann A, et al. Adolescents' Perceptions of Factors Affecting Their Decisions to Seek Health Care. JAMA 273(24): (1995).

13 Gorgen R, Maier B, Diesfield HJ. Problems Related to Schoolgirl Pregnancies in Burkina Faso. Studies in Family Planning 24(5): (1993).

14 Herz EJ, Olson LM, and Reis JS. Family Planning for Teens: Strategies for Improving Outreach and Service Delivery in Public Health Settings. Public Health Reports 103(4): (1988).

15 Hogue CJ, Baden SL. Teen-friendly Family Planning Clinics. Unpublished paper prepared for the

Georgia Campaign for Adolescent Pregnancy Prevention, Summer 1996.

16 International Planned Parenthood Federation (IPPF). Adolescent Fertility and FPA Service Provision in the IPPF/ESEAO Region. 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. IPPF, 1988.

17 International Planned Parenthood Federation. Understanding Adolescents. An IPPF Report on Young People's Sexual and Reproductive Health Needs. IPPF, 1994.

18 International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR). Responding to the Challenge: Preventing Unwanted Teenage Pregnancy in Latin America and the Caribbean. A project paper on five years of funding from the William and Flora Hewlett Foundation. IPPF, 1995.

19 Jay MS, Durant RH, Shoffitt T, et al. Effect of Peer Counselors on Adolescent Compliance in Use of Oral Contraceptives. Pediatrics 73(2): (1984).

20 Kabatesi D. Young People and STDs: A Prescription for Change. Family Health International. AIDScaptions 3(1): (1996).

21 Kim YM, Marangwanda C. Attending Young Clients: Quality of Counseling in Zimbabwe. John Hopkins Center for Communication Programs, 1996.

22 Koontz SL, Conly SR. Youth at Risk: Meeting the Sexual Health Needs of Adolescents. Population Policy Information Kit #9. Population Action International, 1994.

23 Kurz KM, Johnson-Welch C, LeFranc E, et al. Adolescent Fertility and Reproductive Health: A Needs Assessment in the English-Speaking Caribbean for the Pew Charitable Trusts. International Center for Research on Women (ICRW), 1995.

24 Marie Stopes International (MSI). A Cross-Cultural Study of Adolescents’ Access to Family Planning and Reproductive Health Education and Services. Final report to the World Bank, 1995.

25 McCauley AP, Salter C. Meeting the Needs of Young Adults. Population Reports. Series J, No. 41. October 1995.

26 McHarney-Brown C, Kaufman A. Comparison of Adolescent Health Care Provided at a School-Based Clinic and at a Hospital-Based Pediatric Clinic. Southern Medical Journal. 84(11):1340-42 (1991).

27 Nare C, Katz K, Tolley E. Measuring Access to Family Planning Education and Services for Young Adults in Dakar, Senegal. Family Health International, 1996.

18Paxman JM. Clothing the Emperor—Seeing and Meeting the Reproductive Health Needs of Youth. Lessons from Pathfinder's Adolescent Fertility Programs. Prepared for the Rockefeller Foundation, 1993.

29 Pearson S, Cornah D, Diamond I, et al. Promoting Young People’s Sexual Health Services. Report commissioned by the Health Education Authority and Brook Advisory Centres, November 1996.

30 Senderowitz J. Adolescent Health: Reassessing the Passage to Adulthood. World Bank Discussion Papers (272), 1995.

31 Senderowitz J. Health Facility Programs on Reproductive Health for Young Adults. FOCUS on Young Adults, Pathfinder International, 1997.

32 Senderowitz J. Thematic Evaluation: Reproductive Health/Family Planning IEC and Services for Adolescents (Case study: Jamaica and Antigua). UNFPA, 1995.

33 Stedman Y. The Problems of Providing Contraception for Adolescents. Fertility Control Reviews 2(3): (1993).

34 Townsend JW, Dias de May E, Sepulveda Y, et al. Sex Education and Family Planning Services for Young Adults: Urban Strategies in Mexico. Studies in Family Planning 18(2):103-108 (1987).

35 Transgrud R. Adolescent Sexual and Reproductive Health in Eastern and Southern Africa. (Draft). Prepared for USAID/REDSO, May 1997.

36 United Nations Children’s Fund (UNICEF). Youth Health—For a Change. A UNICEF Notebook on Programming for Young People's Health and Development. (Working draft). UNICEF, 1996.

37 Urban and Rural Systems Associates. Improving Family Planning Services for Teenagers. Report submitted to the office of the Assistant Secretary for Planning and Evaluation/Health, Education and Welfare. June 1976.

38 Vadies E, Clark J. Comprehensive Adolescent Fertility Project in Jamaica. PAHO Bulletin 22(3): (1988).

39 Wardle SA, Wright PJ. Family Planning Services—the Needs of Young People: A report from Mid-Staffordshire. The British Journal of Family Planning 19:158-160 (1993).

40 Waszak CS. Quality Contraceptive Services for Adolescents: Focus on Interpersonal Aspects of Client Care. Fertility Control Reviews 2(3): (1993).

41 Weiss E, Whelan D, Gupta GR. Vulnerability and Opportunity: Adolescents and HIV/AIDS in the Developing World. International Center for Research on Women (ICRW), 1996.

42 World Health Organization (WHO). Provision of Adolescent Reproductive Health Services to Adolescents in Indonesia, Nigeria and the Philippines. (Draft). WHO, 1995.

43 Zabin LS, Clark SD. Institutional Factors Affecting Teenagers' Choice and Reasons for Delay in Attending a Family Planning Clinic. Family Planning Perspectives 15(1): (January/February 1983).

] The In FOCUS series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was prepared by Judith Senderowitz and was reviewed by the FOCUS Editorial Board, some outside experts and the staff of the FOCUS Program.