Digest No. 11

Greetings,

The seven postings in this digest come from Cameroon, the Dominican Republic, Malawi, Mexico, South Africa, the U.S., and one unidentified country.

Many of these postings deal with the subject of youth friendly services (YFS).  Maggie Kambalame of Malawi suggests the need to set criteria for YFS.  Olga Mashia from South Africa and Vladimir Jaquez of the Dominican Republic advocate for providing training and education to providers to make services more youth-friendly.  I appreciate Dr. V. Chandra-Mouli providing the link to WHO's valuable resource on this subject: "Adolescent Friendly Health Services: An Agenda for Change." This same publication lists (on page 27) characteristics of adolescent friendly services that may be used to develop the criteria proposed by Maggie Kambalame. This publication also provides helpful examples of where adolescent friendly health services can be offered, including through hospital settings, teen centers, shopping malls, school health clinics, the workplace, and a program in the Philippines linking street children to health centers.

Other postings come from Jane Schueller of the U.S. following up on a posting on cross-generational sex, from Francisco Rosas on the challenges still faced by Mexican youth in accessing contraceptive services, and from Takum Cliford Ticha of Cameroon.

I'd like to end my comments with a word about an ideal place for offering youth-friendly services that hasn't come up yet in the postings…pharmacies and commercial retail outlets. While many services that young people need, such as pre-natal care or HIV counseling and testing, cannot be offered in these commercial outlets, contraceptive services certainly can and are. In fact, from Demographic and Health Surveys around the world, it appears that most young people obtain condoms and oral contraceptives (the two most common contraceptives used by youth) in pharmacies. In many countries, condoms are also available in supermarkets, gas stations and convenience stores. Yet many of these commercial outlets are far from "youth-friendly" and may have proprietors who make young people uncomfortable when asking for a condom, or who keep them hidden behind counters. Taking advantage of the potential for commercial retail outlets to supply young people with contraceptives and making them more youth-friendly would seem to be priority areas for action. So would linking these retail services to other services youth need. For example, how can a young woman purchasing emergency contraceptive pills in a pharmacy get information about other contraceptive methods?  I welcome your thoughts and comments.

Best regards,

Ed Scholl, for the Forum Coordinators

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Forum Digest 11

1. Criteria for Naming Health Services Youth-Friendly
2. Global Efforts to Improve Youth Services
3. Environment and Training Key to Making Services Youth-Friendly
4. Educate Service Providers, Too
5. Cross-Generational Sex, Can Interventions Also Focus on Men?
6. Challenges in Contraceptive Use, Mexico
7. Local HIV/AIDS Effort, Cameroon

1. Criteria for Naming Health Services Youth-Friendly

I want to share lessons that we have learnt on this week's topic. I realise that Amy Weissman [Digest 9] has already given a comment on the same project. In Malawi we have a youth-to-youth project, which is being implemented by Save the Children in Mangochi District. Its main aim is to improve the reproductive and sexual health of youth. One of the strategies we are using is promotion of youth-friendly health services. The project undertook youth-defined, quality dialogues before implementing the project.

My interest is in sharing the lessons learnt after we did an evaluation of the project. We have discovered that, while some clinics are doing well, others are not youth-friendly. These are the lessons we have learnt: Youth-friendly health services should mean the clinics, and not the provider of the service — because the provider might be shifted to another place, which would be the end of it all. So, criteria should be set for calling a clinic or health center youth-friendly. And, make sure that the criteria are clear to every service provider and even the consumers of the service. Also, whenever conducting youth-friendly service trainings that include youth, she or he can be coached to be one of the facilitators of that training, so as to change the attitudinal problems that most of service providers have towards the youth.

 -- Maggie Kambalame, Save the Children, Malawi

2. Global Efforts to Improve Youth Services

Greetings from WHO's Department of Child and Adolescent Health and Development. I read the opening comments by Dr Sheldon with a great deal of interest because it relates to one of our priority work areas. We have two complementary lines of work: firstly, strengthening the ability of health professionals to respond to their adolescent patients more effectively and with greater sensitivity; and, secondly, to make it easier for adolescents to obtain the health services they need (by improving the quality — including the 'friendliness' of health services to adolescents).

Our reading of the situation on the ground is that, in many places, the health services that adolescents — or even adults need — are just not available. (This is in line with what Ms Temitope Abayomi Fadiya has said in her comment.) Even when health services are available, prevailing laws and judgmental health workers withhold them from adolescents; adolescents may not be able to obtain them, e.g. because clinics are located far away and are not accessible to adolescents; and adolescents may not want to obtain them, e.g. because of concerns about privacy and thus are not acceptable to adolescents.

When we consider the barriers that adolescents face in obtaining health services, it is important to remember that this depends very much on 'what the health problem is' and 'who the patient/client is.' A young man may have no hesitation in seeking help for a twisted ankle or a football injury, but he may be very reluctant to do so for an STI. Health services may be easily accessible to adolescents at large, but not to some groups such as children and adolescents on the street.

At WHO, we are working with countries to help them improve the quality — including the friendliness — of health services. We are using methods driven by standards as well as participatory problem identification/problem solving methods. I would like to share with you a resource we have developed titled, "AFHS: An Agenda for Change," which is intended for policy-makers and programme managers (in both developed and developing countries), as well as decision-makers in international organisations supporting public health initiatives in developing countries. It makes a compelling case for concerted action to improve the quality — and especially the friendliness - of health services to adolescents. Drawing upon case studies from around the world, it reiterates that this can be done — and has been done — by non-governmental organisations and government bodies working with limited financial resources. It highlights the critical role that adolescents themselves can play, in conjunction with committed adults, to contribute to their own health and well being. (PDF, 789KB). This resource has been posted on our web site (in the resources section, by title). 

We would be very pleased to hear from people interested in/working in this area.

 -- Dr V. Chandra-Mouli, Department of Child and Adolescent Health and Development, World Health Organization

3. Environment and Training Key to Making Services Youth-Friendly

Thanks to the coordinators of the youth forum. I would like to contribute to the discussion about the physical barriers youth face in accessing health services. Having a waiting space for young people that is away from mainstream patients could be helpful. These waiting areas must be made attractive and interesting for young people. How? While young people wait for help, they could be playing games, learning skills (like computers), sharing information with peers or getting health talks via electro or audiovisual media. They could teach each other how to dance, use drama to convey health messages, learn broadcasting and other useful skills to develop and be empowered.

In our country we have some clinics which have such spaces called chill rooms, where young people come in to relax and chill with their peers. They like coming to this space, which is staffed by skilled peer educators. Although it might not be easy to provide audio visual equipment, playgrounds, fun and games, doing so could be an investment, in the long run, in providing a safe and supportive environment in the quest to improve access to health services to young people.

Sometimes young people feel shy and embarrassed to sit and wait at clinics because adults who know them work there. These adults are sometimes judgmental towards young people who come for contraceptives. The young people also doubt the issue of privacy/confidentiality and feel that their conditions will be divulged in their communities. Therefore, it is important to educate the health workers — security men, clerks, and everybody working in the clinic — to ensure that they treat young people with dignity and respect. In-service training on values clarification should be given to health workers to re-orientate and sensitize them to be youth friendly. Service providers will then be able to differentiate between their personal and professional values.

 -- Olga "Olgies" Mashia, Assistant Director, Youth & Adolescent Health, National Department of Health, Pretoria, South Africa

4. Educate Service Providers, Too

I was reading some of the posts again today, and I find it interesting when Michelle Turton [Digest 6] says parents needs to be educated on parenting skills. That is true. But, if we're talking about medical barriers, I think that service providers should also be educated.

-- Vladimir Encarnación Jáquez, Dominican Republic

5. Cross-Generational Sex, Can Interventions Also Focus on Men?

I am especially grateful for the posting from Amy Weissman about Save the Children's work on cross-generational sex. While everyone recognizes that this is a serious issue for adolescent girls, many of us are still challenged in addressing the problem adequately. The rationale for, and dynamics of, such relationships are not always well-understood. Finding alternative economic opportunities for basic survival is not easy. Changing negative cultural and gender norms that support cross-generational sex can be daunting. And, often, communities feel uncomfortable dealing with the issue, especially with the adult men who engage in such behavior (many of whom are well-respected and admired in their communities, places of worship, workplaces, etc.).

Involving girls and young women in the development of a range of interventions is critical. The continuum created by Save the Children seems like an excellent resource for better understanding the practice of cross-generational sex and for designing appropriate interventions. I would strongly encourage Save the Children to document their experiences in this area and share the continuum widely, as a publication and/or tool, if possible.

At a recent Behavior Change Communication (BCC) Workshop in Tanzania, sponsored by YouthNet, the issue of cross-generational sex was much discussed. In particular, reaching men to end the practice was a key priority. Thus, I am curious to know of other people's experiences in this area. Are there organizations who have designed successful interventions aimed at adult men? How have these worked? Are there technical tools available that could help? I would appreciate any insight that you all might have.

 -- Jane Schueller, Senior Technical Advisor, FHI/YouthNet, U.S.

6. Challenges in Contraceptive Use, Mexico

In my opinion, one obstacle facing adolescents or people under 20 in receiving contraceptive services from health providers is access to information and education on contraceptive technology. Why I am telling this to you all? In my country, there is excellent public health policy, and the initiatives from NGOs working on sexual and reproductive health issues are brilliant. From all fronts, "adolescence is a public health priority." And, in many forums, people claim that Mexico occupies the first place in innovative and creative sexual and reproductive health programs.

But, the reality is that there are so many problems surrounding the sexual and reproductive health of Mexican adolescents threatening so many adolescent lives. Data reveal that Mexico is far from being a model on sexual and reproductive health promotion, especially for adolescents:

• adolescents are starting to have sexual activity at 15 years old (MEXFAM, 1999, Ministry of Health, 2000);
• 366,000 births occurred among women ages 15 to 19 years old (Ministry of Health, 2001);
• delivery and care for unsafe abortion were the main causes of health care for adolescences at public health settings (Celis, 2003);
• the use of contraceptives is extremely low compared with the use of these of other population groups (Ministry of Health, 2001);
• their unmet needs about contraceptive methods are the highest of all social sectors (Ibidem).
  (Full bibliography is available upon requested).

What do adolescents need? With respect to contraceptive services, adolescents have to understand what contraception is and the different kinds of contraceptives: temporals and permanents, hormonals, non-hormonals, emergency contraception, natural methods. Adolescents should have access to all these contraceptives methods. Adolescents should know the benefits related to contraceptive use:

• promoting pleasant, safe, and responsible sexual relations;
• the achievement of better levels of quality of life;
• prevention of both unplanned pregnancies and unsafe abortions;
• promoting and enhancing responsible involving of boys;
• increasing the quality of childbearing and the reduction of mortality among children.

Adolescents should also have access to knowledge and skills about contraception services, especially on how each contraceptive method works and the extent of protection each method offers in preventing pregnancy and HIV and other sexually transmitted infections.

NOT all contraceptive methods are safe and effective for preventing HIV infection and other STIs. Male and female condoms are the ONLY contraceptive methods that protect from HIV and STIs, but adolescents need to have free access to them. Above all, adolescents should learn how to use condoms. With respect to condoms, adolescents should know that these are safe and effective for HIV infection, gonorrhea, syphilis, chlamydia and trichomoniasis. Condoms are little effective against herpes genital and genital warts virus (HPV), and other diseases that can cause sores on skin not covered by condoms.

To end, counseling and informed consent are powerful tools to facilitate access by adolescents to contraceptive services in conservative societies, especially ones that deny that people under 20 are having sexual relations among themselves and with adults. Unfortunately, these sexual contacts are unsafe and unprotected. As such, I want to underlie that "all people, including adolescents, regardless of gender, age, social status, sexual orientation and civil state should to receive high quality health services, including contraceptive services, options and methods, because this is a sexual an reproductive right."

The international orientation from WHO, with respect to contraception for adolescents, should be widely promoted. Legal and normative tools to favor sexual and reproductive health for adolescents should be widely disseminated among health providers within public health settings also. Also, contraception technologies should address adolescents' particular needs. (There is little literature published on this topic.)

These notes were taken from the first section of an Ipas Mexico educational material that I developed for health providers attending adolescents in Mexico. The second part is a normative framework of contraceptive services for adolescents in Mexico. The title of the publication (2004) is, "In Mexico, Adolescents Can Receive Contraceptive Services" and is available in Spanish under the title "En Mexico, Sí Es Posible Ofrecer Servicios de Anticoncepción a Adolescents." You can order a copy by sending an e-mail to ipas@ipas.org.mx or nadineg@ipas.org.mx.

-- Francisco Rosas, Independent Consultant, Mexico

7. Local HIV/AIDS Effort, Cameroon

I am a boy of 21 years old and a Cameroonian by nationality. When browsing the Net, while looking for organisations that help in fighting the HIV/AIDS virus and other STIs, I came across this organization. I was very pleased when I heard that there is a youth seminar currently going on. I really want to learn more about how I can help the organisation that I belong to in its efforts to combat the HIV virus in our community. The youth group that I belong to is called Centre for Artistic Socio Cultural Development, which is in the Ngoketungia division in the north west province of Cameroon. This organisation has five branches. I am involved in the social health branch, which works to combat HIV, AIDS, and other STIs in our community.

 -- Takum Cliford Ticha, Cameroon

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