Assessing youth-friendly sexual and reproductive health services: a systematic review

Although there has been momentum in implementing sexual and reproductive health services (SRH) services in most countries, young people typically remain underserved by these services despite their demonstrated need [1, 2]. In a study of 70 low and middle income countries (LMICs), almost all the countries reported that only 10% or fewer of all adolescent women had visited a health facility in the past 12 months and were informed about family planning [2]. Moreover, 20 to 25% of married adolescents reported an unmet need for contraception according to data from 41 countries [3]. Although adolescents are at an increased risk for STIs and HIV infection in comparison to any other age group [4‐6], adolescents face major barriers in accessing HIV testing and treatment. In sub-Saharan Africa, only 10% of young men and 15% of young women were aware of their HIV status [7]. Even when young people are able to access services, they may feel embarrassed, face stigma on sexual matters, or have concerns about judgmental providers [1, 8]. Youth-friendly health services (YFHS) are a promising approach to delivering health services to meet the SRH needs of young people [3].

Young people require services that support their physiological, cognitive, emotional, and social transition into adulthood [9, 10]. Delivering quality services that are tailored to young people may improve service use, adherence to contraceptive methods, and increase the likelihood of obtaining ongoing care [11, 12]. Therefore, understanding how to best deliver services to young people and evaluating the impact of service delivery is essential to improving youth SRH outcomes. According to the World Health Organization’s (WHO) 2001 Global Consultation on Adolescent Friendly Health Services, SRH services for adolescents should aim to achieve at least one of three goals: (1) provide a supportive environment, (2) improve reproductive health knowledge, attitudes, skills and behaviors, and (3) increase utilization of health and related services [13]. The WHO guidelines for providing YFHS recommends services that are accessible, acceptable, equitable, appropriate and effective [14].

Despite these general guidelines, there is a lack of consensus on what aspects of YFHS are most relevant and important to meet the health needs of young people [15, 16]. Furthermore, several systematic reviews of youth-friendly interventions found insufficient evidence to support the effectiveness of youth-friendly health interventions [15, 17].

Understanding how YFHS are defined and measured may clarify not only how to deliver appropriate services, but also how to assess if these services are effective and to compare different YFHS programs. Although a previous systematic review has assessed the measurement of youth-friendly services at the primary and tertiary levels from a youth-only perspective [18], no studies to our knowledge have focused specifically on the measurement of SRH services for young people, which may have specific needs [18], such as stigma and embarrassment, associated with sexual activity in this age group [19]. This study expands on previous literature to focus on how youth-friendly SRH services are measured worldwide and to identify commonly used indicators from the selected studies that potentially could be used to help develop a standardized method for in the assessing youth-friendly SRH services.

We conducted a systematic review of peer-reviewed published studies measuring youth-friendly SRH services. Because the purpose of this review was to identify indicators that have been used to assess youth-friendliness and not to synthesize the findings on the impact, we included both qualitative and quantitative studies. We included qualitative methods as well as quantitative as this type of methodology can be used to assess constructs that cannot always be quantified and that may identify context-specific issues [20]. We searched for studies published in English between January 2000 and June 2015 on PubMed, Web of Science Core, and POPLINE. Other sources were identified through a snowball method of scanning references in selected sources. The search was conducted using search terms related to youth-friendly health services. Search terms used were “adolescent”, “youth”, “teen”, “teenagers”, “young”, “health services”, “friendly”, “health access”, “clinics”, “health delivery”, and “health center”.

We included studies related to the youth-friendliness of SRH services serving clients aged 10 to 24 years. In cases where studies included individuals aged 24 to 29 years, inclusion criteria was met as long as young people aged 10 to 24 years were the primary population focused on in the study and individuals aged older than 24 years were using facilities for continuation of care or partner specific care. Studies of young people receiving primary health care services were accepted based on the assumption that youth-friendly SRH services are components of primary health care. Abstracts were reviewed for inclusion of SRH services such as HIV, pregnancy, contraception, and sexually transmitted infections (STIs). Excluded studies were specifically related to specialty care such as mental health or tertiary care. If a study was not related to young people receiving care at an existing health facility, such as care received through outreach and education activities, the study was excluded. Studies conducting needs assessments for potential services also were excluded.

Two researchers screened each title and abstract and selected relevant studies based on inclusion and exclusion criteria. If a discrepancy arose, the two researchers reviewed the full article and came to a consensus noting reasons for inclusion or exclusion of the article. During the full review, if articles were missing data, such as detailed methods, questionnaires, or descriptions of measurements, such as surveys or interview guides, the corresponding authors were contacted by email to obtain missing information. No risk of bias or quality assessments were used because this review aims to describe the literature on how YFHS are measured and not to determine the size of an effect or compare study results.

We abstracted data into the data collection table from articles selected for the systematic review to summarize the characteristics of the articles based on setting, study design, instrument used, participants, and indicators used in the studies. As part of the systematic review, indicators used to measure youth-friendliness in selected articles were gathered and synthesized into corresponding domains. The initial domains used in this study were adapted from the WHO Quality Assessment Guidebook: A Guide To Assessing Health Services For Adolescents and Pathfinder’s Clinic Assessment Guidebook: A Tool For Assessing And Improving Sexual And Reproductive Health Services for Youth [21, 22]. The domains used from the WHO tool are “accessible”, “acceptable”, “appropriate”, “equitable”, and “effective” [21]. From the Pathfinder tool, we used “youth involvement”, “services provided”, “environment”, and “educational activities” [22]. Two additional domains, “staff characteristics and competency” and “confidentiality and privacy,” were added by the researchers as a number of indicators were more appropriately grouped under these new domains and to incorporate indicators that did not fit into the predefined domains. Both researchers reviewed placement of indicators in the corresponding domains and if a discrepancy arose, the researchers reached an agreement through additional discussion.

Our initial search (Fig. 1) yielded 6762 unduplicated records. All titles and abstracts were initially screened by two researchers. Reasons for exclusion at this stage included not specifically measuring youth-friendliness, needs assessments for not yet existing facilities, not related to young people’s SRH, or the sample population was not within the age range of our inclusion criteria. We then retrieved 44 articles for full text review. The full review resulted in the final selection of 20 studies that met all of the inclusion criteria (Table 1). Studies included five mixed method studies [23‐27], five qualitative studies [28‐32], two case-control studies [33, 34], three randomized controlled trials (RCTs) [35, 36], and six other quantitative studies [12, 37‐41]. All studies that used RCTs or case-control designs were located in LMICs.

Of the 20 studies included in the review, 13 were located in sub-Saharan Africa, three in North America, three in Europe, and one in Asia. Six of the studies were conducted in high income countries and 14 in LMICs. Twelve of the studies were conducted with young people as respondents, three measured provider or staff responses, and five combined a mix of young people, provider, and non-clinical staff respondents.

No existing youth friendly assessment tool was used by more than one study, and no core set of indicators was commonly used between studies. Nine studies used a hybrid of questions from existing tools in addition to their own questions [23, 26, 31, 32, 34, 37‐40]. Some YFHS assessments were based on those developed by international organizations such as the WHO, International Planned Parenthood Federation, UNAIDS, and Pathfinder International, as well as from national toolkits and institutes. Five of the six studies conducted in high income countries included in this review used distinct validated or existing tools in contrast to only half of the studies conducted in LMICs [12, 23, 26, 32, 39].

The studies included in the review did not use similar tools or indicators to assess YFHS. In fact, almost two-fifths of the indicators were unique to the specific study. While there are many tools available for assessing YFHS, no study used the same tool. This variation highlights the need to standardize the way in which YFHS are measured with a minimum of a core set of indicators to enable findings to be more easily compared across settings. This variability has limited the comparability and generalizability of assessments of the effectiveness of youth-friendly services. While standardized tools will provide a core set of indicators, these tools may need to be adapted or augmented for different cultural contexts [42, 43]. The presence of unique indicators may suggest that there are distinct contextual settings for health service delivery or may reflect a researcher’s particular interests. For example, indicators in the domain of confidentiality and privacy and the domain of staff characteristics and competency were included in all studies in this review, but measured differently. Indicators in other domains, such as young people’s involvement and educational activities, may need further development, adoption, and more widespread use if prioritized as important for YFHS. In each case, researchers and practitioners need to reach a consensus on the priorities and the specific measurements. Given the importance of their perspective, young people should also play a role in providing input in the development of priorities and measures. In addition to providers and youth input, community stakeholders, researches, NGOs, and public institutions can play a collaborative role in establishing these priorities [42, 44, 45].

We expected that youth-specific indicators would have featured more prominently in our results for measuring youth-friendly SRH services. Young people’s involvement in YFHS development, delivery, and evaluation, along with appropriate environments, were the least likely indicators to be measured. The ten most commonly used indicators to measure YFHS in the identified studies (Table 3) emphasized convenient opening hours, nonjudgmental attitudes, ease of access to location of facility, receipt of adequate information from providers, services that are affordable or free, friendly and respectful staff, reasonable waiting times, and confidentiality. It is notable that while some indicators such as confidentiality and nonjudgmental attitudes are important in the delivery of SRH services, none of these indicators is specific to youth-friendliness and may be more relatable to general access and quality of care, an underlying theme in the assessment of indicators in this review. Improvements in providing health care overall can coincide with increased services utilization among adolescents [46]. Similarly, many of the indicators related to clinic environment were not specific to youth-friendliness and were more a measure of basic facility standards (e.g., clean water) or services (e.g., not corrupt).

Some evidence also suggests that young people may not prioritize what providers and programmers view as youth-specific approaches [47], such as youth-only spaces, entertainment, and welcoming décor; they may prioritize issues such as confidentiality and costs [16] far more. For example, a survey of youth preferences in Kenya and Zimbabwe found young people valued integrated services, low-cost service, short wait times, and staff with friendly attitudes [16]. In contrast, young people did not prioritize choosing services that assured youth-specific spaces such as youth-only and single-sex only facilities [16]. Some studies have found that youth-only spaces may not be effective in increasing service use [16] as young people may realistically fear the stigma associated with seeking SRH care, given negative views and societal values about sexuality of young people [48]. Lack of clear prioritization among measurements of youth-specific SRH needs suggests the term “youth-friendly” may often be no more than an attempt by clinical and public health professionals to develop what they perceive to be attractive services. In part, the absence of a standardized tool or indicators for measuring youth-friendly SRH services is indicative of a vague definition of exactly what constitutes YFHS, but also why there is limited evidence for the effectiveness of YFHS.

The results show that little is known about precisely what dimensions are most needed to serve the SRH needs for young clients and whether the most relevant indicators would vary from the indicators used to measure services for adults or younger children, or services for primary care versus SRH services. For example, issues of confidentiality may be more important to young people given cultural attitudes regarding pre-marital sexual relationships. Furthermore, no studies examined the use of different services to assess uptake or to differentiate age-specific needs such as education or long acting contraceptive counselling. Only one study mentioned LGBTQ youth, suggesting future research needs to understand if there are specific service needs for LGBTQ youth and other marginalized sub-populations and to what extent these needs are being met [47]. Understanding which domains are most important in delivering health services to young people when there are only finite resources available needs to be further assessed.

Our review also confirmed that evidence of the impact of YFHS on SRH service use and health outcomes is limited. Other reviews assessing the effectiveness of research on YFHS similarly found the need for a more rigorous approach to developing and using tools to test the effectiveness of YFHS strategies on health outcomes [15, 18].