We conducted a total of 25 interviews (including pilot interviews), 23 (14 female, 9 male) of which were used for data analysis. We did not use two pilot interviews (methods b&c) in analysis as they did not reflect the overall data collection methodology used (method a). Interviews captured perceptions and opinions for both recent users and non-users (reported visited within the past six months) of local health services (15 users/8 non-users), including knowledge and perception of YFS initiatives. Additionally, participant’s opinions on two potential alternative health service delivery methods were collected.
Perception of current health services
Young people were generally dissatisfied with the current public health services in Soweto. Dissatisfaction was linked to a lack of resources, long waiting times, and poor quality of care. These reflect well-documented barriers to acceptable health care services [
7],[
15]. Staffing shortages, insufficient diagnostic equipment (such as x-rays) and drug stock-outs were reported. Because of frequent drug stock-outs, clinics often only offered basic medications such as antibiotics or generic painkillers like Panado© which are readily available at small shops and supermarkets. Participants felt that going to a clinic was an unnecessary step that did not always result in better outcomes.
‘They’ll give you Panado©. Any pain killer or they’ll just say they’re out of stock. So you might as well just buy your own pain killer and not go to the clinic’ (Male).
Youth who did visit local clinics often faced extensive waiting times. Young people interviewed reported waiting between 30 minutes and several hours to see a nurse or doctor. Discontent was aggravated by a perception that their wait was often a result of nurses taking prolonged tea-breaks, leaving early, or dismissing their duties. Overall, participants felt nurses were rude, did not establish a sense of confidentiality or show respect to their needs. Some differentiated this behaviour from doctors, indicating that while doctors were scarce they perceived them to be more attentive and committed to their jobs.
Dissatisfaction was heightened by underlying feelings of inequity in choice and access to quality services. Participants described a distinct variability and hierarchy of services. Private clinics were viewed as the pinnacle of health care services, described as trustworthy, clean, fast, reliable, and better staffed and stocked than publicly funded healthcare facilities. Those who had accessed private health services (6 interviewees) indicated not only satisfaction with the services, but gratefulness in their ability to pay and avoid the public system. Chemists or pharmacists, who can do quick diagnosis and prescribe over-the-counter drugs, were considered to be better than public health facilities but not as good as private clinics. When neither of these services was accessible due to financial barriers, young people relied on free public services.
When faced with attending a public clinic, participants discussed three action strategies: avoidance, fatalistic acceptance, and manipulation of the system. When not feeling well, patients first reported avoiding the public clinics. Those interviewed primarily relied upon home remedies or information from libraries, the Internet and online chat rooms. Utilisation of the public health system often only came after all other treatments failed and access to private services was financially infeasible. At this point, there was a sense of fatalistic acceptance.
Interviewer: ‘At what point would you think about going to the clinic?’
Participant: ‘When it is serious. But I don’t like clinics so I don’t usually go.’
Interviewer: ‘What makes it serious?’
Participant: ‘When you have taken all other methods and they don’t help… you must go’ (Female).
“Ah, it’s it’s it’s quite bad. Some people don’t even have the money to go to private doctors, so they have no choice. They they have to go there, and be in the queue for long hours. It’s not it’s not good” (Female).
Some participants discussed being gossiped about, judged, or even turned away if they were perceived to have the ability to afford private services. They were told they were trying to ‘
take advantage’ of free services that are not ‘
meant for them’. Others discussed feeling that if clinic workers judged them to be of a lower class, they treated them as if they were deserving of poor services and treatment. When faced with this type of treatment, young people felt they did not have the social capital to make complaints or demand better service because the services were free. One patient discussed how this perpetuates poor treatment from the nursing staff because they will not be held accountable for their behaviour.
“Cause some—they do go to the clinic but then, like I said, the other problem is that you find people who are judgmental or rude. You know? So that’s the reason why they are afraid to go” (Female).
‘The one in [neighbourhood 1], like, there are nurses who are treating white people, colours, like there are all types of people who are going there. So I think maybe first that the advantages is that you have people who treat people good because they know there are other people who will generate results. When they are treated bad, the report it right away. So I feel like they should always treat us like people. [At neighbourhood 2], they take advantage. There are only black people there. They take advantage of that… they just mistreat people because they are at the local’ (Female).
There were, however, clinics that participants reported as being ‘good’ clinics, those that were regarded as having greater resources, shorter waiting times, and friendlier staff. Access to these clinics was limited. A National Department of Health policy states that patients must visit their nearest clinic first and get subsequent referrals if the patient would like to go elsewhere [
18]. To access ‘good’ clinics, several participants discussed manipulating the system by using local addresses or another family member’s information.
“Yeah so you just go there and just write my name and the new address where I’ll stay at that moment in that village. So just write there and they’ll say ‘ok, fine”(Male).
Participant: ‘Well… there are some good clinics…but these days they’re strict at clinics. They’ll check your address so you can’t go to any clinic you want. Cause then you want to go to the favourite clinic, so they get packed there and other clinics are empty. So now they first check your address before attending you’.
Interviewer: ‘How do you feel about that?’
Participant: ‘No… it’s bad. Because we go there knowing we get the better service than the other clinics. But we can’t go… unless I change my address’ (Female).
Knowledge of YFS initiatives
Overall, knowledge of YFS programmes was very low; of 23 participants interviewed only three reported ever hearing about ‘youth-friendly services,’ none of whom were able to express extensive knowledge of the programme’s purpose or activities. After the interviewer described the YFS programme, some participants acknowledged these services might exist but recognised the lack of knowledge as a problem.
‘I think there is one at our clinic, but I’ve never been to that… I’ve never heard people say, speaking anything about or going there. Yeah, like cause sometimes they don’t know about it. It’s just there’s a centre there, people don’t really know what’s going on… they’re not really clued in on what’s going on’ (Female).
“I think the services are ok…the only thing is: are youth attending them? You know, going and learning about them? The youngsters, they need to be more, um, what can I say, they need to be made aware of that, that these services are there for us to go” (Female).
Most participants agreed that it sounds like a good programme, and that nurses should be trained on respect for all persons, confidentiality, dedication, as well as proper sensitivities to young people’s needs. For the most part these needs were related to sexual health, including sexually transmitted infections, HIV/AIDS, and pregnancy. Additionally, general health education, diabetes, and counselling were brought up as important health issues facing these young people.
YFS was developed from the loveLife programme, so participants were also asked if they had ever heard of the loveLife’s peer educators, groundBREAKERS. Eighteen of the twenty-three participants indicated that they had heard of groundBREAKERS, the majority of whom (14 of the 18) correctly matched a description to the programme. Overall, participants perceived the groundBREAKERS programme positively, and found them relatable, trustworthy and a good source of health education.
Attitudes toward alternative health services
This study also examined the participant’s opinions of two alternative health service delivery systems: School Based Health Clinics (SBHC) and Community Health Workers (CHW). There was no particular service that was preferred. While most of the participants were excited to discuss these potential services, a few participants seemed sceptical about the likelihood of these services being implemented in Soweto - potentially reflecting their feeling of disenfranchisement with current health service interventions.
‘No. It could work. I’m just thinking training nurses to be friendly and non-judgmental- Oh! [raises eyebrows in disapproval]…’ (Female).
In general, reactions to SBHC were positive; all but one young person interviewed said they would have liked to have had a SBHC at their school when they were younger. Perceived benefits of a SBHC included fewer missed class hours to visit clinics, improved educational performance, and greater health awareness. While there was no consensus regarding the demographic characteristics (age, gender) of potential SBHC staff, participants generally agreed that independent nurses not affiliated with the school should staff SBHC, pointing to uneasiness with the idea of teachers having access to the health information of the students. Another concern that arose was related to a sense of inequity- that if these services were in schools they would then only be available to current students and not be available to out-of-school youth or young adults that are no longer school-aged. Some also discussed concern for older people being excluded from these services, and suggested that more outreach services should be available to them.
In general, the CHW model most accommodated the feeling for greater equity in access to health services. Participants liked the idea of having health services visit them in their home environment, however it was widely agreed that CHWs should not target certain houses or skip houses, to avoid stigma, promote confidentiality and ensure no one needing health services was missed.
‘For example, they go to this house and maybe from this house you’re skipping this one and going to that one [points to three imaginary houses]. What if this person would die today? [pointing to skipped house] If I did come it would be fine and I would be seeing he would be having sickness’ (Male).
Health education and HIV testing and treatment were among the services participants would most like to see offered by CHWs. Other services that were discussed included general check-ups, health education and assessments for obesity, blood pressure, diabetes, and illness. While there was little consensus regarding the demographic characteristics (age, gender) of potential CHWs, participants agreed that CHWs should be clearly identifiable (with a uniform or badge) so that safety could be ensured.