Provision of adolescent and youth-friendly services in public health facilities in Migori County, Kenya

INTRODUCTION

According to the World Health Organization (WHO), adolescents and youth (AY) are individuals aged 10-19 and 15–24 years, respectively.¹ As AY transition to adulthood, they face various challenges including health as they are in a unique phase of development.² According to WHO, health services for the AY include counseling on sexual reproductive health (SRH), information and education, sexual and gender-based violence (SGBV), screening for sexually transmitted infections (STIs), life skills training, mental health, and drug and substance use.² It is imperative to respond to these challenges by providing friendly health services. Neglecting the needs of young people can lead to poor outcomes such as risky sexual behaviors that can predispose them to early and unintended pregnancies, unsafe abortion, school dropout, STIs, and SGBV.³ The consequences of the poor outcomes affect the future of AY negatively hence the need to have comprehensive policies that establish joint actions with strategies that include promotion of AY health.⁴ Development of corroborated guidelines to aid services in health, and other sectors and advising governments on the health of AY responsive health systems are some of the WHO’s roles in improving the health of young people.⁵ The WHO’s Global accelerated action for the health of adolescents (2017) aims to guide governments to plan and react to health needs of adolescents.⁶ Global and national guidelines exist to guide the provision of adolescent and youth-friendly services (AYFS).^6,7 These guidelines stipulate that AYFS should be available at convenient hours with available service providers; suitable and meet AY expected needs; provided in a suitable package; provided in the right way and are suitable to improve health of all AY without discrimination, and AY can receive the health services they need. Health services should be provided in a nonjudgmental and respectful manner. Additionally, AY should be aware of the available services for them, and appealing service delivery points should be available while engaging and coordinating with relevant stakeholders and the community in the AYFS provision.⁵ Implementation of the AYFS protocols influences the delivery of the right service to adolescents and improves the care-seeking behavior of these adolescents.

Kenya’s devolved governance structure, including the health system, provide renewed attention to address long-standing challenges in the provision of AYFS.⁷ Kenyan government has inclusion of AY matters in the country's development agenda outlined in National Guidelines for Provision of AYFS (2016).⁷ Despite existence of AYFS policies in Kenya, national coverage of AYFS is low at 10%, while Migori County was at 21%.⁸ Inadequate training of health care providers (HCPs) on AYFS provision, poor health infrastructure, stock outs on commodities and supplies, minimal awareness creation, and weak coordination of AYFS was attributed to the low AYFS coverage.⁸ Migori County strategic plan (2018-2022) states that 80% of the public facilities should provide AYFS.⁹ However, the implementation of AYFS in public health facilities in Migori County remains a challenge with only 62 (39%) public facilities providing AYFS. Although there has been marked improvement in the AY health indicators over time in Migori County, SRH problems remain a major cause of ill health among adolescents in Migori. ⁸ In addition, there has been no assessment of the implementation of Kenya AYFS guidelines in Migori County. This study therefore aimed to assess provision of adolescent and youth-friendly services in public health facilities in Migori County, Kenya.

METHODS

Study design and setting

A cross-sectional study design was employed. The study setting was government funded, public health facilities in Migori County. Migori County is in southwestern Kenya and borders Homabay, Kisii, and Narok counties, Tanzania, and Lake Victoria. It has a population of 1,116,436 people.¹⁰ The county has 275 health facilities, of these 159 are government owned and are served by 838 clinical officers and nurses, who were the target population for the study.

Study population

Study population comprised clinical officers and nurses, and facility-in-charges who provided or managed AYFS in public health facilities in Migori County. The county currently has four healthcare delivery systems structured into four levels, which represent the referral pathways. Level 1 is the community level, level 2 is dispensaries, level 3 health centers, and level 4 sub-county referral facilities. All health facility levels were represented in the study.

Sampling size calculation and sampling procedure

A sample of 114 of 159 public health facilities was calculated using the Taro Yamane method.¹¹ Multistage sampling of 114 public health facilities was done from which 210 health care providers (HCPs) were sampled using simple random sampling. Three facility-in-charges were purposively selected to represent each of the county's three Levels of the healthcare delivery system (Level 2-Dispensary, 3-Health Centre, and 4-Subcounty health facilities).

Data collection and management

Key informant interview guide, health facility observation checklist, and structured questionnaire were used to collect data. The three-point Likert structured questionnaire was self-administered, this was filled by the HCPs. Key informant interviews were conducted among health facility-in-charges focusing on their roles in the execution of the 2016 AYFS guidelines. The facility checklist used was as adopted from the 2016 Kenya National guidelines for provision of AYFS. The checklist focused on the standard and quality provision of AYFS among the selected facilities. For validity and reliability, the study tools were pretested among HCPs supporting provision of AYFS in Uriri and Awendo Sub-County hospitals in Migori County.

Data analysis

The statistical package for social sciences (SPSS) version 24.0 (IBM Corp., Armonk, NY, USA) was used to enter, clean, and analyze quantitative data. Descriptive statistics were performed on the demographic characteristics and study variables through frequencies and percentages. NVivo 9 software was used for transcribing and coding the qualitative data and analysis following content, thematic framework approach, and comparison with standards from the literature review.

RESULTS

The study was anchored on the 2016 Kenya National Adolescents and Youth Friendly Services (AYFS) guidelines, against which the provision of AYFS was measured. The AYFS guidelines stipulate strategies and standards for provision of AYFS. Provision of AYFS is measured by determining if the AYFS are equitable, accessible, acceptable, appropriate, and effective. Data collection took place between March and May 2023, 208 healthcare providers participated in the study.

Demographic characteristics

Most 121 (58%) of the respondents were female, with 153 (74%) practicing as nurses. Nearly half 93 (45%) were between 31-36 years of age and the majority 166 (80%) had attained a diploma, and 148 (71%) of the respondents had worked at their current workstation between 1-5 years (Table 1).

Equitable adolescent youth friendly services

Equitable AYFS was assessed against policies and procedures being available to guide the nondiscriminatory provision of AYFS. Majority of the health facilities 83(74%) did not have in place these AYFS policies. Nearly all facilities 110(98%) were administering AYFS without discrimination, in addition, 135 (65%) of the respondents agreed AYFS provision includes reaching vulnerable subpopulations of young people (Tables 2-3). These findings were further corroborated with facility in-charge interview feedback that stated that, provision of adolescent and youth services is for all regardless of where they come from, regardless of their political affiliation and any other background whether they are poor or rich…. we make sure that we have everything at one corner we make sure that they get it without any discrimination. Those coming from vulnerable areas and even the disabled ones, we made sure that we give them priority FII003.

Accessible adolescent youth friendly services

Accessible AYFS were assessed by seeking information on the cost of AYFS services, facility operating hours, signage to facilitate access to service delivery points, AYFS being conveniently located for ease of access in the health facilities, and community and AY being informed on the range of available AYFS. Majority of facilities 87 (78%) were offering free AYFS, 66 (59%) had convenient hours for AYFS service provision, 98(88%) had the community informed on the benefits and availability of AYFS, 94 (84%) had AY informed on the range of AYFS services and how to obtain them, 73 (65%) had signage available and visible at the point of service delivery, and nearly all the facilities 104 (93%) were conveniently located for ease of access of services. Further, most of the respondents 145 (70%) reported that training on AYFS led to the setting up of AYFS in the facility. Slightly more than half 117 (56%) reported that stakeholders were aware of AYFS and 131 (63%) reported that facilities conducted community outreaches involving community health volunteers (CHVs) and community health extension workers (CHEWs) to reach the AY at the rural and hard to reach areas, respectively (Table 2-3). These findings were further corroborated by a facility-in-charge who stated that, first, we ensure accessibility of commodities that the youths might need and then are friendly to these youths so that they can be free to talk to us on their needs. Then we consider the opening hours of the facility and if there is an activity, we talk through the youth lead such that if there are some youths who want to come to the facility at odd hours, we can stay at the facility so that we give services to these youths. We usually liaise with the Youth Lead. Some policies are put in place within the facility such as the consent from parents FII002.

Acceptable adolescent youth friendly services

Acceptable AYFS were assessed by seeking information on appointments scheduling, time spent with the healthcare provider, providers being respectful and non-judgmental, having referral and follow-up, Information Education and Communication (IEC) materials being provided in a familiar language, having policies on privacy and confidentiality, having an appealing and clean environment, AY being actively involved in designing, assessing, and providing services, and AY involvement in decision making. In almost all the facilities 103 (92%) AY were able to consult the service providers at short notice, and 105 (94%) reported that the facilities providers spent adequate time with the AY. In nearly all the facilities 110 (98%), service providers were respectful and non-judgmental to AY clients, in 107 (96%) of the facilities, service providers ensured privacy and confidentiality to AY clients.

CHMT: county health management team; SCHMT: sub-county health management team.

Additionally, most respondents 145 (70%) reported that training in AYFS promoted value clarification and attitude transformation (VCAT). However, it's worth noting that in a majority of the facilities, 79 (71%) policies and procedures that guarantee AY client privacy and confidentiality were not available. About half of the facilities 58 (52%) had materials provided in a familiar language, easy to understand, eye-catching, and responsive to the needs of AY. Majority of the health facilities 65 (58%) were not actively involving AY in designing, assessing, and providing services, and further about half 57 (51%) of the facilities did not involve AY in decision-making on AYFS provision (Table 2-3).

Appropriate adolescent youth friendly services

Appropriate services were measured by seeking information on the availability of a package that fulfils the needs of AY clients and having in place referrals, linkages, and follow-up systems and procedures. Results on appropriate AYFS provision, show that 63 (56%) of the facilities had a package that fulfills the needs of AY. Further, the majority, 77 (69%) had referral, linkages, and follow-up systems and procedures in place, more so, 117 (56%) respondents reported that there was an elaborate referral system to ensure services not available at the facility could be obtained from a nearby private health facility. However, despite 56% of the respondents saying that there was an elaborate referral system, less than half of the respondents 83 (40%) were aware of the AYFS county referral directory.

About half of the respondents 106 (51%) reported that the AYFS plans were integrated into the facility's annual work plan (Table 2-3). A facility in charge had this to say. We offer the services of reproductive health; we teach them about how to prevent pregnancies in those services. We also offer youth-friendly services in our facility. We only have one staff trained. We do involve other people in the facility. We have the youth peer provider (YPP), and we have a youth-friendly corner at our facility. The YPPs sit at the youth-friendly room where they advise these youths and then for those who cannot reach the family planning room, we offer the services at the youth-friendly room FII002.

Effective adolescent youth friendly services

Effective AYFS Service provision was assessed by seeking information on whether service providers had competencies and training on AYFS, relevant and appropriate equipment and supplies, and service providers using evidence–based protocols and guidelines to provide services. Results on the effectiveness of AYFS provision show that 71 (63%) of health facilities had service providers with the required competencies to work with and provide AY. Slightly more than half, 63 (56%) of facilities had service providers not trained to provide AYFS, although nearly all the respondents reported they were aware of AYFS. Only slightly above half 112 (54%) had been oriented or sensitized on the provision of AYFS. In addition, 142(68%) respondents were aware of the strategies, approaches, and service delivery models for AYFS provision. Results show that in 86 (77%) of the facilities, service providers were not using evidence-based protocols and guidelines to provide services (Tables 2-3).

A facility in charge had this to say; We only have one staff trained. In total we are three; one clinical officer and two nurses FII002. We used to have one trained worker but was transferred FII001. We have a good number of staff in the facility approximately 10 that is both clinical officers and nurses. But not all of them are trained, the numbers who are trained on AYFS are two clinical officers and two nurses the other team is getting what is called orientation or mentorship FII003.

DISCUSSION

Most respondents in this study were female and practiced as nurses with diploma qualifications. In Kenya most of the healthcare workers studying nursing are female, and a majority of the medical training colleges offer diploma courses.¹² Most respondents had worked in the current health facility for 1-5 years. The current Kenyan national guidelines on the provision of AYFS were launched in 2016, and many of these respondents were already deployed in their current workstations.

Equitable AYFS include services reaching vulnerable subpopulations of young people. Several studies found that adolescents and youth in humanitarian settings should obtain a variety of health services that they need without any form of discrimination^.6,7,13,14 The study revealed that nearly all facilities were administering AYFS without discrimination albeit having no policies and procedures in place to guide nondiscriminatory provision of AYFS. A study conducted in South Africa in 2018, identified discrepancies in implementation of the policies at the facility level, raising the need to join efforts to develop systems that promote implementation of policies and guidelines within primary healthcare facilities. The AYFS quality assessment guidebook states that there should be no restriction in provision of health services to adolescents irrespective of age, sex, social-cultural background, ethnicity, disability, or any other form of difference. ¹⁴ Young people living with disability have unique interventions and programs depending on their culture, therefore the need to put into consideration their social-cultural needs.^.13 Additionally, the Kenya National Guidelines for Provision of Adolescent and Youth Friendly Services 2016 states that all AY including those of vulnerable sub-populations and those in humanitarian settings should obtain a variety of health services they need without any form of discrimination.⁷ Accessibility of AYFS may be promoted by training HCPs on AYFS, this was seen to catalyze setting up of AYFS in the health facilities, creating awareness of AYFS among stakeholders, and conducting community outreaches to reach the AY and parents at the rural and hard to reach areas. Efforts by healthcare providers to involve the community in provision of AYFS are likely to promote access to AYFS. To enhance the accessibility of the AYFS to AY, community members, including parents, should be aware of the services for them to participate in the provision of these services as well as encourage the AY to take up the services.^7,15 A study conducted in 2018 found that young people value privacy and confidentiality, enabling an environment during interaction with service providers, competent service providers, and affordable health services.¹⁶ Healthcare providers should be available to provide health services to AY considering AY desired times of the day without any form of barrier to access the services.⁷ To enhance the accessibility of AYFS to AY, Community members, including parents should be aware of the services for them to participate in the provision of these services as well as encourage AY to take up services. Efforts should be put in place to ensure there is a good referral system that ensures AY receive services they need as close to them as possible.⁷ High cost of services particularly transport, consultation fee, medication and a negative HCPs mind frame, deficient resources in the facilities on adolescent health are among the key individual barriers to accessing AY information and health services.¹⁷Acceptable AYFS include AY spending enough time with the healthcare provider during visits to the health facility, providers being respectful and non-judgmental, having referral and follow-up, providing young people with Information Education and Communication (IEC) materials in a language they understand, having policies on privacy and confidentiality, having an appealing and clean environment, AY being actively involved in designing, assessing, and providing services, and AY involvement in decision making. Existing guidelines urge that involving the AY in relevant aspects of the provision such as peer education enhances the acceptability of the services by AY.^6,7 A study conducted in Kisumu showed that AY who interacted with HCPs for consultations had positive remarks on their experience with most (>90%) of the AY reporting that HCPs treated them in a responsive favorable manner by taking adequate time in attending to them. ¹⁸ The policies and guidelines that provide standards for provision of AYFS should be available and functional at any given.^5,7 A study conducted on the utilization of AYFS in Ethiopia revealed that government service providers were not using the national youth guidelines despite the guidelines being available for them.¹⁹ Further, ensuring affectionate and enticing health services influenced the adolescents to uptake the health services. Many of the facilities were not actively involving the AY in designing, assessing, decision-making, and providing AYFS. National AYFS guidelines direct that involving AY in every phase of AYFS provision from assessing their health needs to designing, implementing, monitoring, and evaluating the AY programs is the best way of meeting the needs of AY.⁷ It is paramount to have broader interventions that include families and communities along with AY-specific clinics and AY support groups to enhance curbing the barriers for this very vulnerable group.¹⁵

Regarding appropriate AYFS provision, most respondents reported that there was an elaborate referral system to ensure services not available at the facility could be obtained from the nearest private health facility. The design of AYFS should provide room for linkages and referrals to ensure AY obtain the services timely and as close to them as possible.²⁰ However, despite 56% of the respondents saying that there was an elaborate referral system, less than half of respondents were aware of the AYFS county referral directory. There are required actions to be taken to enhance effective AYFS referral systems. These actions include putting national and county-level referral directories in place, sensitizing HCPs on effective referral systems, enhancing functional referral systems, availing mechanisms for monitoring, and evaluating the quality of the referral system.⁷ About half of the respondents reported that the AYFS plans were integrated into the facility's annual work plan. At the country level, it is a paramount step to ensure presence of policies and strategic plans that focus on health needs and suitable service delivery to the AY.²¹ Further on observation, most facilities had a package that fulfilled the needs of AY and had a referral, linkages and follow-up systems, and procedures in place. Needs of the adolescents and youth must be considered to avoid poor outcomes such as risky sexual behaviors that can predispose them to, early unintended pregnancies, unsafe abortion, school dropout, sexually transmitted infections, and sexual violation and abuse.³ As stated earlier, involving AY in every phase of AYFS provision from assessing their health needs, to designing, implementing, monitoring, and evaluating the AY programs is the best way to meet the needs of AY. Nearly all respondents were aware of effective AYFS provision. However, only 54% had been oriented or sensitized on provision of AYFS. Most respondents were aware of the strategies, approaches, and service delivery models for AYFS provision. A study found that expectations of young people can be met by creating AY-targeted clinics and enhancing public and private service delivery points.²² In addition, to ensure effective AYFS, HCPs must have the required competencies for providing health services to AY guided by recommended standard operating procedures and policy guidelines. Concerning these, during observation of AYFS provision within the health facilities, not all service providers had competencies on AYFS needs and very few had been trained on AYFS. A study conducted in 2014 recommended that improved skills including practices and competencies among HCPs on care for adolescents can be achieved through training.²³ Further, in most facilities, service providers were not using evidence-based protocols and guidelines to provide services. A study on utilization of AYFS in Ethiopia revealed that government respondents were not using the national youth guidelines despite the guidelines being available.¹⁹

CONCLUSION

As seen in the discussion, HCPs in public health facilities in Migori County are knowledgeable and equipped on equitable, accessible, acceptable, appropriate, and effective AYFS provisions. However, the inadequate AYFS training among HCPS and poor implementation of existing policies including weak engagement of young people in AYFS significantly hinder the effective provision of AYFS in public health facilities. The public health facilities are also poised to provide AYFS; however, poor referral and linkage systems impair AYFS delivery.

Recommendations

There is a need for regular updates on AYFS among the HCPS to improve their skills and knowledge on AYFS provision, the HCPs should also enhance total involvement of AY during all stages of AYFS provision. The county ought to avail and disseminate AYFS policies and reinforce the adherence of the use of all the recommended AYFS policies, guidelines, protocols and SoPs during AYFS provision. Further, there is a need to put county-level referral directories in place and sensitize HCPs so as to enhance effective referral systems within the county.

ACKNOWLEDGEMENTS

The authors would like to thank all the healthcare providers who participated in the study. We also appreciate the County and Sub-County adolescent and youth health coordinators and the research coordinators who ensured a smooth process of data collection within the health facilities.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Adolescent health. Available at: https://www.who.int/health-topics/adolescent-health#tab=tab_1. Accessed on 20 February 2023.
2. 2. Coming of age: adolescent health. Available at: https://www.who.int/news-room/spotlight/coming-of-age-adolescent-health. Accessed on 20 February 2023.
3. 3. Nkole T, Mukatimui M, Munalula K, Zulu JM. Adolescent-Friendly Health Services in Public Health Facilities in Lusaka, Zambia, MEASURE Evaluation. Available at: https://www.measureevaluation.org/resources/wp-19-230.html. Accessed on 20 February 2023.
4. 4. Gomes C. Education, Work, and Reproductive Health among Adolescents in Latin America and the Caribbean. Adv Appl Sociol. 2013;03(02):142-50.
5. 5. Making health services adolescent-friendly. Available at: https://apps.who.int/iris/bitstream/handle/10665/75217/9789241503594_eng.pdf?sequence=1. Accessed on 20 February 2023.
6. 6. Global Accelerated Action for the Health of Adolescents (AA-HA!). Available at: https://apps.who.int/iris/bitstream/handle/10665/255415/9;jsessionid=B309C8C56E5EEFA24FA2F606422AB847?sequence=1. Accessed on 20 February 2023.
7. 7. Guidelines for Provision of Adolescent & Youth-Friendly Services. Available at: https://faces.ucsf.edu/sites/g/files/tkssra4711/f/YouthGuidelines2016.pdf. Accessed on 20 February 2023.
8. 8. Service Availability and Readiness Assessment Mapping (SARAM) Kenya 2013. Available at: https://data-archive.hhfa.online/index.php/catalog/51. Accessed on 20 February 2023.
9. 9. Migori Municipality Integrated Development Plan 2018-2022. Available at: https://repository.kippra.or.ke/handle/123456789/1289. Accessed on 20 February 2023.
10. 10. Republic of Kenya Kenya Demographic and Health Survey 2014. Available at: www.DHSprogram.com. Accessed on 20 February 2023.
11. 11. Sample Size Determination in Survey Research. Available at: https://sdiarticle4.com/prh/doc/Revised-ms_JSRR_58400_v1.pdf. Accessed on 20 February 2023.
12. 12. Kenya Health Policy 2014 to 2030. Available at: http://publications.universalhealth2030.org/ref/d6e32af10e5c515876d34f801774aa9a. Accessed on 20 February 2023.
13. 13. Groce NE. Adolescents and youth with disability: Issues and challenges. Available at: https://discovery.ucl.ac.uk/id/15132/. Accessed on 20 February 2023.
14. 14. Quality assessment guidebook: a guide to assessing health services for adolescent clients. Available at: https://apps.who.int/iris/handle/10665/44240. Accessed on 20 February 2023.
15. 15. Teasdale CA, Alwar T, Chege D, Fayorsey R, Hawken MP, Abrams EJ. Impact of Youth and Adolescent Friendly Services on Retention of 10-24-Year-Olds in HIV Care and Treatment Programs in Nyanza, Kenya. JAIDS. 2016;71(2):e56-9.
16. 16. Brittain AW, Williams JR, Zapata LB, Pazol K, Romero LM, Weik TS. Youth-friendly family planning services for young people: a systematic review. Am J Prev Med. 2015;49(1):S73-84.
17. 17. Mutea L, Ontiri S, Kadiri F, Michielesen K, Gichangi P. Access to information and use of adolescent sexual reproductive health services: Qualitative exploration of barriers and facilitators in Kisumu and Kakamega, Kenya. PLoS One. 2020;15(11).
18. 18. Onyando J, Oluoch M, Njuguna RS. Factors influencing effectiveness of youth friendly centres in Kenya: a case of Kisumu county. Available at: https://www.researchgate.net/publication/326735898_factors_influencing_effectiveness_of_youth_friendly_centres_in_kenya_a_case_of_kisumu_county. Accessed on 20 February 2023.
19. 19. Motuma A, Syre T, Egata G, Kenay A. Utilization of youth-friendly services and associated factors among youth in Harar town, east Ethiopia: a mixed method study. BMC Health Serv Res. 2016;16(1).
20. 20. Brittain AW, Williams JR, Zapata LB, Pazol K, Romero LM, Weik TS. Youth-Friendly Health Services in Ethiopia: What Has Been Achieved in 15 Years and What Remains to be Done. Available at: https://www.researchgate.net/publication/357427407_Youth-Friendly_Health_Services_in_Ethiopia_What_Has_Been_Achieved_in_15_Years_and_What_Remains_to_be_Done. Accessed on 20 February 2023.
21. 21. Deogan C, Ferguson J, Stenberg K. Resource needs for adolescent-friendly health services: estimates for 74 low- and middle-income countries. PLoS One. 2012.
22. 22. Blair M, Rigby M, Alexander D. Issues and opportunities in primary health care for children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project. Available at: https://www.perlego.com/. Accessed on 20 February 2023.
23. 23. Albuhairan FS, Olsson TM. Advancing adolescent health and health services in Saudi Arabia: exploring health-care providers’ training, interest, and perceptions of the health-care needs of young people. Adv Med Educ Pract. 2014;5:281-7.