In August of 2016 my counterpart Edwin approached me with an idea of building an adolescent-friendly health room at our clinic. Edwin is the clinical officer at our village dispensary and is incredibly passionate about adolescent health. He said he had seen such rooms at other clinics and had heard they were effective in making teenagers feel more comfortable coming to access services. I thought it was a cool idea but I told him that we first needed to do research to understand the problem better, in order to see if his proposed solution was appropriate. Through a series of anonymous surveys and discussions with students, teachers and parents in our ward, we learned some pretty interesting and startling information about youth health in our region:
- Teenagers in our area commonly become sexually active in secondary school when they are 15-16, though some start as young as 11 or 12
- Teens typically do not use condoms when they begin to have sex. Many we asked noted lack of education as a major factor
- Last year, 10 female students out of 170 left our ward’s secondary school due to pregnancy
- Many students said they would not feel comfortable going to the local clinic to ask a sexual health question, for an HIV test, or to get treatment for a problem, because people would see them and ask why they were there
This last issue is a major one, and it has led many NGOs, development workers, and government officials to ask tough questions: “Can we effectively reduce the burden of adolescent health issues such as HIV/AIDS and early pregnancy if adolescents do not feel comfortable going to health centers?” and “How can we make health services accessible and attractive for adolescents?” After some careful research into the subject, the respective answers appear to be “no” and “it’s complicated”.
What are adolescent-friendly health services and what benefits might they bring?
A focus on adolescent-friendly health services (AFHS) must start with a recognition that adolescents are a consistently overlooked and underserved population. Adolescents face unique and formidable barriers to access including fear of being seen at clinics, operational barriers such as lack of transportation and inconvenient operating times, and real concerns that staff members will be hostile or judgmental. AFHS initiatives must seek to identify and reduce barriers to access of clinic services by adolescents, in whatever form they might take. Promotion of AFHS within a community could yield two major benefits:
Reduced transmission and increased early treatment of HIV/AIDS: Teenagers, in particular young women, are one of the major at-risk populations in Tanzania for new HIV infection. While education initiatives are critical in protecting youth of both sexes from HIV, education alone is not enough if adolescents do not feel comfortable visiting their clinics for testing, treatment and counseling. Telling young people who are sexually active to “know their status” may not have much impact if they fear or are otherwise unable to go to the clinic to learn that status.
Reduced Early/Unplanned Pregnancy: Early and unplanned pregnancies are a major barrier for keeping young women in school in Tanzania, as it is almost never possible for a young woman to continue with her studies once she is pregnant, for logistic, financial and legal reasons. If a young women becomes sexually active but is unable or unwilling to go to the clinic for counseling or to receive birth control, her ability to prevent unwanted pregnancy is severely diminished.
How “friendly” are Tanzanian clinics?
Recently, 19 PCTZ health volunteers, roughly 50% of those in-country, responded to a survey about their respective clinics and health centers. Here is what they said:
Compassionate Care: 4/19 volunteers said they had witnessed verbal abuse or harassment of patients by clinicians. No instances of physical abuse by clinicians were seen. Verbal abuse included shaming/chastisement of teenagers for sexual behavior and of new mothers for coming to the clinic without clothes for their newborns. It is possible that this has been under-recorded, as volunteers may not be present when abuse is happening. It is also likely too that this issue is less pronounced than it was in the past, as the Tanzanian government has made efforts to educate clinicians against this sort of behavior.
Confidentiality: 18/19 volunteers indicated that their clinic did not strictly honor patient confidentiality. In the minority of cases clinicians would openly talk about cases within earshot of non-clinicians without suitably obscuring the patient’s identity. More often, volunteers said clinicians gave an effort to protect patient confidentiality but were hindered by the clinic’s setup or small size (patients could hear others’ consultations through a window or open door) or that patient files were carelessly left out in the open for others to see.
Use by Adolescents: Only 2/19 volunteers indicated that adolescents frequently used their clinic, omitting those who had come due to pregnancy. Most indicated that they had only saw non-pregnant adolescents on occasion, typically for an illness/malaria test. Most reported that it was extremely rare for an adolescent to come for counseling, to request birth control or for an HIV test.
What can we do as PCVs to promote youth-friendly services?
Edwin and I ultimately decided to go ahead with his idea to build a separate health room for adolescents. PCVs have a lot of different priorities to balance however and a building project is not going to be right for everyone. Even so, there are many small things that PCVs can do that can help reduce barriers to access for teenagers.
- Talk with your clinicians. They are probably aware of this issue, and they might even have some ideas about how to address it that they haven’t had time to act on
- Organize youth programming at the clinic. If there is adequate space, start an afterschool program for kids at your clinic (you could use maua/mazingira mazuri or ACT3 material to start). Alternatively, take students for a one-time clinic fieldtrip. As they become familiar with the clinic and its staff adolescents will feel more comfortable going there for help in the future
- Use clinicians as counterparts for youth-related programming at the school or elsewhere (Malaria training, Skillz, etc.). Again, as youth get to know clinicians they will feel more comfortable coming to them with problems
- Talk with your community. Poll adolescents/providers/villagers about barriers to access for adolescents in your village, and see what you can do to address them
- For instance, if operating times are an issue, would your clinicians be willing to stay open later one evening a week to counsel/treat adolescents?
- Help improve confidentiality at your clinic. Many PCVs report seeing patient files lying all over the place. Many facilities have high patient volume and there may be little free time to organize these files. PCVs meanwhile have plenty of free time, and helping the clinic organize its files can make a big difference to both confidentiality and daily operations
If you have questions, comments or a story about your experience, shoot me an email: Christopher.valleau@gmail. There is still a lot we don’t know about this issue and we would love to hear from you.