One of the six strategies Her Choice applies in the field addresses strategy III: improving access to SRHR services for young people. We do this by training health staff, improving health services and facilitating referral for SRH services between schools and health centers.
The long-term goal of the Her Choice programme is to support the creation of child marriage-free communities in which girls and young women are free to decide if, when and whom to marry. The six intervention strategies are based on evidence, which shows that the most consistent results of targeting child marriages are achieved by the combination of investing in girls and creating more conducive social, economic, policy and legal environments. One of the Her Choice strategies is improving access to youth-friendly SRHR services for girls by improving health services and by actively referring girls to health workers.
To increase young people’s access to SRHR services, the Her Choice programme offers training to health staff on youth-friendly attitudes and SRHR services and supports health centers to make the health center more accessible to young people by taking youth-friendly measures. In addition, referral systems between schools and health facilities are being set up or improved. These activities are designed to lead to the intermediate outcomes of more health workers feeling confident and able to provide SRHR services to young people and more health facilities offering youth friendly health services, with as result that more young people know about the availability of SRHR information and services and access these if they need.
Training of health staff
Health staff taking part in the midline study was asked whether they had received any training on providing tailored SRHR services for young people during the past two years, which corresponded with the period between Her Choice baseline (conducted in 2016) and midline (conducted in 2018) studies. In all countries, excluding Ethiopia, a large number of staff at midline reported they had received such training by Her Choice partners. With respect to the topics of the training received, most often mentioned topics were contraceptive methods, followed by early marriage, early pregnancy, puberty, sexual relationships, and youth friendly methods.
Findings indicate that in the midline, in most project countries, relative to baseline, as a result of the training more staff reported feeling capable and able to answer all young people’s questions – in Nepal, Mali, Benin, Ghana and Uganda all interviewed staff reported so.
At midline, virtually all health staff stated that their health facility offered services to young people, including unmarried and school going youth. Only in Ethiopia did some health care staff indicate they did not provide services to unmarried people. At baseline, this picture was more diversified, in no country did all health staff report providing such services.
In charge of health care facilities were asked an open question about the kinds of measures they had taken to make their center more youth friendly. Responses were categorised using a shortlist of six measures, including: services for young people are private, health workers know harmful consequences of child marriage, health workers know harmful consequences of female genital mutilation, referral system are established with school(s), opening hours allow youth to attend, and services are available to all youth (married and non-married). At midline, compared to baseline, many more health facilities had taken measures to make their health center friendly to young people: Measures most often taken across countries related to adjusting opening hours to allow young people to attend, and making services available to all youth – married and unmarried.
Partners in most countries, excluding in Nepal and Pakistan, reported that they had facilitated the set-up of referral mechanisms between schools, communities, and/or peer educators and health facilities. School principals were asked whether referral mechanisms were in place between their school and a health clinic, NGO and/or other health provider in case a student needs SRHR-related services or information. All schools in Bangladesh, Mali, Benin and Uganda had such referral system, whereas in other countries, half or fewer schools had such a system.
Girls’ knowledge and utilization of SRHR-related services
At midline, the share of interviewed girls (aged 12-17) who knew of SRHR-related services has increased compared to baseline. Midline figures for the percentage of single girls knowing where to access SRHR services were all above 50% (Nepal lowest with 51.6%) and ranged to a high of 79.4% among single girls in Mali. The most notable increases in proportions of girls with this knowledge were found in Pakistan, Senegal, Mali and Ethiopia (Figure 1).
Figure 1: Share of single girls (%) who know where to access SRHR services, at midline and baseline
Married girls were generally more aware of SRHR services than single girls. This finding is not entirely surprising given a considerable number of married girls will have accessed a health service related to pregnancy and delivery. At midline, overall, the share of married girls who knew of SRHR-related services had increased when compared to baseline data. Most notable increases were found among married young women in Bangladesh, Pakistan, Nepal and Senegal. For married young women figures for awareness of services ranged from 69.2% in Nepal to 93.3% in Pakistan.
Girls who reported being aware of SRHR services, were asked whether they had ever utilized these services. Overall, and as expected, utilization was higher among married girls, probably due to pregnancy, or contraception related visits. Utilization of SRHR services by single girls in the midline study had increased compared to the baseline in most countries, except Nepal, Burkina Faso and Benin, and sometimes dramatically: notably in Pakistan and Senegal.
Figure 2: Share of single girls knowing about SRHR services who visited a clinic for SRHR services (%), at midline and baseline
By far the central reason stated across countries as to why many girls who knew of the services did not utilise SRHR-services related to not having had an SRHR-related problem or question – in Nepal and Ghana, for example, respectively 97% and 98.6% of young women indicated this formed their main reason. For those who had experienced a SRHR-related problem, the most commonly cited reason for not utilizing health services had to do with shame.
Challenges and recommendations for post-midline
None of the health staff trained mentioned having received what might be considered a comprehensive training on youth friendly health services. It is important to note in this regard that HC partners need to align their work with government policies on, in this case, SRHR provision for young people. While doing so might mean that training might be less ‘comprehensive,’ in the long-run, alignment is deemed more conducive to bringing about change.
Very few partners reported to having given support to health facilities in terms of putting in place measures to make the services more accessible to young people and more youth-friendly, except for some partners in Bangladesh, Benin, Burkina Faso, Ghana, and Mali. Her Choice alliance members realized that it is not always clear to local partners and staff in health centers what being youth-friendly implies and therefore have designed a visualization tool called: ‘Assessing Youth Friendly Health Services’. The tool has been developed with a number of aims in mind, including:
- facilitating an evaluation of Youth Friendly Health Services (YFHS)
- facilitating (multi-)stakeholder discussions on a particular health service with a view to improving understanding between stakeholders, which can lead to
- facilitating the improvement of existing YFHS through multi-stakeholder engagement.
Although utilization of SRH services by girls who need these services has increased compared to baseline, somewhat worrying is that the most commonly cited reason for not utilizing health services had to do with the girl feeling ashamed to go. This points at that shame about SRH issues should be more addressed in SRHR education to youth and in education to health staff who should reach out to young people with a youth friendly and understanding attitude.