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Adolescent and Youth Reproductive Health: 10. Adolescent- and Youth-Friendly Reproductive Health
Study Session 10 Adolescent- and Youth-Friendly Reproductive Health Services
Introduction
Adolescent and youth reproductive health services should have distinctive features so that they will attract, meet the needs of, and retain young people as clients. Adolescent- and youth-friendly reproductive health (AYFRH) services are services that are accessible to and acceptable by young people. In this session you will learn about the characteristics of adolescent and youth-friendly services in terms of relevance to the providers, the health facility itself, and the programme design. You will also learn how you can interact with young people when consulting them on reproductive health (RH) issues.
Learning Outcomes for Study Session 10
When you have studied this session, you should be able to:
10.1 Define and use correctly all of the key words printed in bold. (SAQs 10.1, 10.2 and 10.3)
10.2. Describe characteristics of AYFRH services. (SAQs 10.1 and 10.2)
10.3 Discuss and identify barriers to the utilisation of AYFRH services and strategies to address them at your level. (SAQ 10.1)
10.4 Describe the elements included in assessing young people for RH needs. (SAQ 10.3)
10.1 Reproductive health services for young people
10.1.1 Characteristics of adolescent-and youth-friendly reproductive health services
Reproductive services that are accessible to, acceptable by and appropriate for adolescents and youth are called adolescent- and youth-friendly reproductive health services. They are in the right place, at the right price (free where necessary), and delivered in the right style to be acceptable to young people. The characteristics of AYFRH services relate to the service providers, the health facility itself, and the programme design. You see these characteristics in Boxes 10.1–10.3 below.
In Box 10.1 you see the characteristics related to the health facility.
Box 10.1 Health facility characteristics
- Convenient space/location
- Convenient hours
- Comfortable surroundings
- Peer counsellors available.
Box 10.2 Characteristics of the service provider
- Specially trained staff. The service provider is trained in adolescent- and youth-friendly services.
- Respect for young people. The service provider has respect for young people.
- Privacy and confidentiality. The service provider ensures that there is privacy and keeps the matters regarding the RH problems of the young person confidential.
- Adequate time for client–provider interaction. The service provider gives enough time to interact with the young person.
The four characteristics in the above box relate to the service provider.
Stop reading for a moment and think about this for yourself. You are the service provider. Do you think you have the above four characteristics?
Health facilities that are adolescent- and youth-friendly have a convenient space or room which young people who are in need of sexual and reproductive health services can use without being seen and heard by others. If there is no such space for the young people, they will be waiting for services in the midst of older clients and this will make them uncomfortable.
Stop reading and think of your health post. Is it possible to arrange a convenient room or space for young people?
Arranging a convenient space or room for young people is not enough by itself. The room should have enough space to ensure privacy and it should be located in a convenient area where the young person can feel comfortable. Otherwise, they may be too embarrassed to come for the services.
Young people also need to have services in hours that are convenient for them.
Stop reading and think about this from your experience. Are the service hours at your health post convenient for young people?
The third set of characteristics relates to the overall programme design of the reproductive health services for adolescents and youth. This is presented in Box 10.3 below.
Box 10.3 Programme design characteristics
- Involvement of young people in design and continuing feedback. In addition to their involvement during the design, the young people are allowed to give their feedback on the services/programme and their feedback is addressed.
- Involve the young in the health committee to improve the adolescent-friendly services.
- No overcrowding and short waiting times.
- Affordable fees.
- Publicity and recruitment that inform and reassure the young people. The services at the health facility are publicised and young people are made aware of the services.
- Both young men and young women are welcomed and served.
- Wide range of services available.
- Necessary referrals available.
- Educational material available on-site and to take away.
- Group discussions available.
- Alternative ways to access information, counselling and services.
- Parents and community involved to promote and support AYFRH services.
Stop reading and think of your experience. Which of the above programme design characteristics exist at the health post in your community? Could you do anything to improve the service offered by your health post?
In Study Session 13 you will learn how you can assess whether the services provided at your health post are adolescent- and youth-friendly or not.
10.1.2 Ethiopian AYFRH service standards
Following the development of the National Adolescent and Youth Reproductive Health Strategy, the Federal Ministry of Health has developed standards for youth-friendly services.
We have presented the standards in Box 10.4.
Box 10.4 Ethiopian adolescent- and youth-friendly service standards
- The service outlet provides service supported by the existing national policies and processes that give due attention to the rights of young people.
- Appropriate health services that cater to the reproductive and sexual health needs of young people are available and accessible.
- The service outlets have a physical environment that is organised in a way that is conducive to the provision of AYFRH services.
- The service outlet has drugs, supplies and equipment necessary to provide the essential service package for youth-friendly health care.
- Information, education and communication (IEC)/behavioural change and communication (BCC) consistent with the minimum service package is provided.
- The service providers in all service outlets have the required knowledge, skills and positive attitudes to effectively provide youth-friendly RH services.
- Young people receive an adequate psychosocial and physical assessment and individualised care based on the national standard case management guidelines/protocols.
- The service outlet has a system that ensures that the necessary referral linkage is made and ensures continuity of care for young people.
- Young people participate in designing and implementing youth-friendly services, and mechanisms are created to enhance the participation of parents and members of the community in contributing towards sustainable youth-friendly services in their localities.
10.1.3 Services to be provided in adolescent- and youth-friendly services
Stop reading and think of the services you would wish to provide for young people as part of an AYRFH service at your health post.
The Ethiopian AYFRH service guidelines say that the services that should be provided in AYFRH services include those which are presented in Box 10.5.
Box 10.5 Services intended to be provided in adolescent- and youth-friendly services
- Information and counselling on sexual and reproductive health issues
- Promotion of healthy sexual behaviours through various methods including peer education
- Family planning information, counselling and methods including emergency contraceptive methods
- Condom promotion and provision
- Testing services: pregnancy, HIV counselling and testing
- Management of STIs
- Abortion and post-abortion care
- Antenatal care (ANC), delivery, postnatal care (PNC) and pregnant mother-to-child transmission (PMTCT) services
- Appropriate referral linkage between facilities at different levels.
Stop reading and think of your experience. Looking at the list of the services in Box 10.5, is there any service that you can’t provide at your level?
In the previous sessions in this Module you have learned how to provide most of these services. In Study Session 11 you will learn how to provide care during pregnancy, labour and the postnatal period. If you feel unsure about your ability to provide the services, you should re-read the relevant sessions. Make a note to ask your Tutor about any remaining uncertainties.
10.2 Barriers to RH service utilisation
10.2.1 Barriers to utilisation of RH services for young people
What factors could affect the utilisation of reproductive health services by young people in your area?
There are many factors that affect the utilisation of available sexual and reproductive health services by young people. We can categorise these as: individual/personal factors, institutional factors, and social/cultural factors. Some examples of these factors are presented in Table 10.1.
| Individual/personal factors | Cultural/social factors | Institutional factors |
|---|---|---|
| Marital status | Awareness level of the communities | Judgemental health workers (Figure 10.1) |
| Gender norms | Attitudes towards young people’s sexual behaviour | Locations: distant facilities, services very close to where adults are being served |
| Sexual activities | Attitude towards AYRH services | Timing: RH services being provided may not have convenient times for young people. If it takes an unreasonably long waiting time to get the service, it is likely that they won’t use it. |
| Schooling status | Parent–child interactions | Cost: if the RH services are not provided at reasonable cost, young people can’t access them |
| Childbearing status | Peer pressure | Space: if young people are not counselled and served in a private space, they will be afraid that they will be seen by adults |
| Economic status | ||
| Rural/urban residence |
Stop reading and think of your experience. How does each of the factors listed under the individual/personal and cultural/social categories affect service utilisation by a young person? For instance, if the young person is unmarried and female, she will be less likely to use RH services. In communities where the awareness level is high and people are supportive of RH services for young people, it will be easier for young people to use RH services.
We believe that you have important roles in addressing these barriers to RH service utilisation. In the next section we will suggest some specific things you could do to reduce these barriers.
10.2.2 Your roles in addressing these barriers to RH service utilisation
As you have already learned in previous sessions of this Module, young people face major physical, psychological and social changes in life during which they may have many questions and concerns about what is happening in their life. While this period of life is generally considered as a healthy time of life, it is also a period when many behaviours that negatively affect health start. As a Health Extension Practitioner you have important contributions to make in helping those young people who are well to stay well, and those who develop health problems get back to good health.
In this section you will learn how you can do this and thereby reduce the barriers to RH service utilisation by young people. You can do this in a number of ways. Some of the things you can do include:
- Recognising that young people have the right to access RH information and services.
- Improving and developing a positive attitude towards young people’s sexual and RH needs. If you encounter a young person who is already sexually active, you need to help them in a non-judgemental manner.
- Providing them with appropriate information, counselling and services aimed at helping them maintain safe behaviours and modify unsafe ones (i.e. those that put them at risk of negative health outcomes).
- Identifying and managing health problems and unsafe behaviours.
- Referring them to nearby health centres/hospitals for further help when necessary.
- Educating the community so that they can understand the needs of adolescents, and the importance of working together to respond to these needs.
10.3 The interaction with young people at the health post
10.3.1 Establishing good rapport with young people
Some young people may come to your health post on their own, alone or with their friends. Other young people may be brought to the health post by a parent or a relative. Depending on the circumstances and the nature of the problem, the young person could be anxious or afraid. In addition, young people may be reluctant to disclose information on sensitive matters if their parents or guardians, or even spouse are also present.
If you do the following, you will be able to establish good rapport with young people. This will help the young people to disclose their RH problems.
- Greet the young people in a friendly manner. (Figure 10.2)
- Explain to the young people that:
- you are there to help them, and you will do your best to understand and respond to their needs and problems
- you would like them to communicate with you freely and without hesitation
- they should feel at ease and not be afraid because you will not say or do anything that affects them negatively
- you will not share with anyone any information that they have entrusted you with, unless they give you permission to do so.
- If the young person is accompanied by an adult, explain to the accompanying adult in the presence of the young person that you want to develop a good working relationship with the young person and this means that at some stage you may need some time to speak to the young person alone.
10.3.2 Taking the history of the young person’s problems
As the health issues of young people are mostly sensitive in nature, it is good to start with the least sensitive or non-sensitive issues. For example, instead of asking at the start ‘Are you sexually active?’ which is very threatening to the young person, starting with ‘Where do you live?’, ‘Do you go to school?’ will help to open up the young person. Where possible, use the third person (indirect questions). It is good to ask first about friends’ activities rather than directly about their own activities. For example, rather than ask a young person directly, ‘Do you drink alcohol?’ you could ask, ‘Do any of your friends drink?’ If the young person replies, ‘Yes’, you could then ask, ‘Have you ever joined them?’ This can lead to other questions, such as ‘How often do you drink?’, etc.
In addition to the presenting problems, the young people may have other health problems and concerns but may not say anything about them unless directly asked to do so. It is useful to go beyond the presenting problem and ask them if they have any other health problem. Consider using the HEADS assessment to help you do this.
HEADS is an acronym for:
H Home
E Education/employment
E Eating
A Activity
D Drugs
S Sexuality
S Security
S Suicide/depression
Table 10.1 suggests issues you can raise and discuss with the young person using HEADS.
| Home | Where they live and with whom they live Whether there have been recent changes in their home situation How they perceive their home situation |
| Education or employment | Whether they study/work How they perceive how they are doing How they perceive their relations with their teachers and fellow students/employers and colleagues Whether there have been any recent changes in their situation |
| Eating | How many meals they have on a normal day What they eat at each meal What they think and feel about their bodies |
| Activity | What activities they are involved in outside study/work and what they do in their free time |
| Drugs | Whether they use substances like tobacco, alcohol, or others If they use any substances, how much do they use; when, where and with whom do they use them |
| Sexuality | Their knowledge about sexual and reproductive health Their knowledge about their menstrual periods and any questions and concerns that they have about their menstrual periods Their thoughts and feelings about their sexual behaviour Whether they are sexually active, and if so, the nature and context of their sexual activity Whether they are taking steps to avoid sexual and reproductive health problems Whether they have in fact encountered such problems (unwanted pregnancy, infection, sexual coercion), and if so, whether they have received any treatment for this |
| Safety | Whether they feel safe at home, in the community, in their place of study or work, on the road (as drivers and as pedestrians), etc. If they feel unsafe, what makes them feel so |
| Suicide/depression | Whether their sleep is adequate and whether they feel unduly tired How they feel emotionally Whether they have had any mental health problems (especially depression) and if so, whether they have received any treatment for this Whether they have had suicidal thoughts and whether they have attempted suicide |
You can use the points in the table mainly for those young people who come to your health post for the first time. Depending on their context, you may need to adjust the points you discuss with them when they are not first-timers. Besides, you may not need to discuss all the points in the table if the young person is courageous enough to disclose their needs directly. In this case you can directly discuss their concerns. For example, if the young person tells you that they want you to give them condoms, you can now start discussing sexual behaviour instead of asking them about home, education, activity, etc.
Even if young people come to the health post for health problems other than RH, you should assess them for sexual activity (whether they are at risk of STIs/HIV or pregnancy), substance abuse, and sexual abuse.
10.3.3 Doing physical examinations
It is only necessary to do a physical examination in some contexts. If a young person comes to you for condoms and cannot spend time with you, it is enough to briefly discuss sexual behaviour with them and then give them what they want. Sometimes, you may need to do a physical examination in order to diagnose the problem the young person has and to help them. Some parts of the physical examination can cause embarrassment. For example, vaginal examination for a vaginal discharge may cause embarrassment in a young woman. Therefore avoid doing vaginal examination unless there is a strong indication of need for this. For example, for a young woman in labour you should do a vaginal examination to assess the progress of labour. You should not do a pelvic examination of a virgin.
As part of the physical examination, check the following:
- Temperature
- Pulse rate
- Presence of anaemia
- Presence of undernutrition
- Presence of swelling or tenderness in the abdomen.
You have learned how to do these in the Antenatal Care Module.
In Box 10.6 you will see ways to make the physical examination less stressful for the young person.
Box 10.6 How to make the physical examination less stressful a young person
- Respect the young person’s sensitivity about privacy.
- Explain what you are doing before you begin each step of the examination.
- Protect their physical privacy as much as possible. Allow them to keep their clothes on except for what must be removed. Make sure to cover the parts of the body that are exposed. Never leave any part of the body exposed when not being examined.
- Reassure the client that any results of the examination will remain confidential.
- A good rapport and relationship between you and the young person is essential. Try to establish trust.
- Provide reassurance throughout the examination.
- Give constant feedback in a non-judgemental manner, ‘I see you have a small sore here, does it hurt?’
Based on what you get from the history taking and physical examination, you should counsel and provide services for each specific problem the young person has. For STIs, HIV/AIDS, unsafe abortions, contraception, emergency contraception, sexual abuse and substance abuse refer to the respective sessions on how to respond to the specific needs of the young person. For pregnancy, childbirth and postpartum-related needs, you will learn how you should provide care in the next session.
Summary of Study Session 10
In Study Session 10, you have learned that:
- Reproductive services that are accessible to, acceptable by and appropriate for adolescents and young people are called adolescent- and youth-friendly reproductive health (AYFRH) services.
- The characteristics of AYFRH services relate to the service providers, the health facility itself, and the programme design.
- The service provider characteristics include specially trained staff, respect for young people, privacy and confidentiality, and adequate time for client–provider interaction.
- Health facility characteristics include convenient space/location, convenient hours, comfortable surroundings, peer counsellor availability.
- Programme design characteristics include involvement of young people, no overcrowding and short waiting time, affordable fees, wide range of services available, and necessary referrals available.
- Services intended to be provided in AYFRH services include information and counselling on family planning, promotion of healthy sexual behaviours, SRH issues management of STIs, antenatal care, delivery care, PMTCT, postnatal care, post-abortion care, testing for HIV and pregnancy, and referral services.
- There are many factors that affect the utilisation of available sexual and reproductive health services by young people and these include individual/personal factors, institutional factors and social/cultural factors.
- You have important roles in reducing these barriers to service utilisation.
- You need to establish good rapport while interacting with young people in order to properly identify and respond to their needs.
- You can consider using the HEADS (HEADS is an acronym for Home, Education/employment, Eating, Activity, Drugs, Sexuality, and Suicide/depression) assessment for proper history taking in a young person.
Self-Assessment Questions (SAQs) for Study Session 10
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
First read Case Study 10.1 then answer the questions that follow it.
Case Study 10.1 Fatima
Fatima is a 16-year-old young woman who lives in Roda kebele. The health post in Roda kebele is just 30 minutes’ walk from Fatima’s home. Fatima is sexually active but wants to delay pregnancy until she reaches 20 years old and finishes school. She knows the health post in her vicinity provides reproductive health services including contraceptives. She doesn’t want to visit the health post at times when most adults will be there for services.
One day after school she went to the health post only to find it was closed. She tried on another day but this time the guard at the gate shouted at her, saying the services were not for school girls of her age. As she was in desperate need of contraceptives she tried once more to visit the facility but this time along with adult clients. She had to sit and wait a long time until all the adults had received services. The adults’ expressions were discouraging but she managed to get into the consultation room and told the health worker that she was in need of contraceptives. The health worker at the health post, without taking Fatima’s full history, said she was already exhausted and had to close the facility. In addition, she said contraceptives were not for girls of her age and asked her why she was sexually active at this age. The health worker has never been trained in adolescent- and youth-friendly reproductive health service provision. Fatima is married and is her husband’s third wife. But the health worker had no interest in exploring Fatima’s history.
SAQ 10.1 (tests Learning Outcomes 10.1, 10.2 and 10.3)
- a.Is Roda health post providing adolescent- and youth-friendly reproductive health services? If yes, explain why. If not, explain why not.
- b.What are the barriers to Fatima’s utilisation of RH services? Categorise them under individual, cultural/social and institutional factors.
Answer
- a.Roda Health Post is not providing AYFRH services. This is because of the following reasons:
- The health worker at the health post is not trained in adolescent and youth-friendly services and is not welcoming to and supportive of the access to RH information and services by young people.
- The health worker and the guard do not show respect for young people.
- The adults who were waiting for the services were not supportive. They did not seem to know that young people have the right to access health information and services.
- The health worker did not give enough time to Fatima.
- The service hours were not convenient for young people.
- b.Barriers to Fatima’s utilisation of RH Services
| Individual/personal factors | Cultural/social factors | Institutional factors |
|---|---|---|
Schooling status: she is a student who went to the health post with her school materials; the adults, the guard, and the health worker were judgemental based on their belief that a student who is ‘unmarried’ should not be sexually active and hence shouldn’t come to the health post. | Awareness level of the communities Attitudes towards young people’s sexual behaviour Attitude towards AYRH services | Judgemental health worker Space/locations: Fatima has to wait for the service with adults Timing: it was not convenient for Fatima |
First read Case Study 10.2 then answer the questions that follow it.
Case Study 10.2 Adane
Adane is an 18-year-old man who wants to get tested for HIV. He went to the nearest health post, which is an hour’s walk from his home. When he reached it he found that it did not provide a testing service. The health worker at the facility told him that she had no idea where he could get this service.
While he was at school discussing it with his peers, he learned that there was a health centre in town which provided the service, but it was about four hours walk from his home, i.e. an eight-hour round trip. He wanted to visit the health centre but had no money to pay for the transport.
SAQ 10.2 (tests Learning Outcomes 10.1, 10.2 and 10.3)
- a.What required standard is missing from this facility?
- b.What could be done to respond to the needs for HIV testing young people in Adane’s kebele?
Answer
- a.An appropriate referral linkage is the required standard that is missing. The health worker at the health post should have awareness of where a VCT service is available and be able to refer young people to it.
- b.As it is a long way for young people to go for a VCT the health centre could arrange an outreach service for Adane’s kebele and other distant kebeles in the health centre’s catchment areas.
SAQ 10.3 (tests Learning Outcomes 10.1 and 10.4)
A 17-year-old girl comes to the health post with a cough. Explain what other conditions you will assess her for in addition to the cough?
Answer
Even if she comes to the health post for health problems other than RH, you should assess her RH using the HEADS assessment. HEADS can be used to assess whether she is at risk from STIs (including HIV) or might become pregnant. You should also assess whether she abuses substances and/or is being sexually abused.