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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