Sociodemographic Profile of participant ASRHS providers
Table 1 shows the sociodemographic characteristics of the 159 respondents. There were 54.5% males and 45.5% females, aged 15-65 years old, whose majority (43.1%) was between 26 and 35 years old.
Most of the respondents were nurses (80%), followed by general medical practitioners (6.3%); 57.8% had a diploma (A1) level.
Table 1: Social demographic characteristics of respondents
Variables
|
Total N
|
Percent
|
Gender
|
Female
|
70
|
45.5
|
Male
|
84
|
54.5
|
Age years
|
|
|
|
15-25
|
5
|
3.1
|
26-35
|
69
|
43.1
|
36-45
|
56
|
35.0
|
46-55
|
26
|
16.3
|
56-65
|
3
|
1.9
|
Education
|
|
|
|
Secondary (A2)
|
23
|
14.9
|
Diploma (A1)
|
89
|
57.8
|
Bachelors (A0)
|
37
|
24.0
|
Masters
|
5
|
3.2
|
Qualification
|
|
|
|
Medical doctor
|
10
|
6.3
|
Nurse
|
129
|
80.6
|
Midwife
|
3
|
1.9
|
Social worker
|
3
|
1.9
|
Public health specialist
|
6
|
3.8
|
Clinical specialist
|
1
|
0.6
|
Psychologist
|
1
|
0.6
|
Lab technician
|
4
|
2.5
|
Management officer
|
2
|
1.3
|
Total
|
|
159
|
100
|
Quality of services
Table 2 shows that a higher proportion of the respondents (56.3%) were working with private health facilities, mainly form Nyarugenge district health facilities (28.8%). The least number of participants was in Huye 9(5.6%). The number of staff on board varied from 0 to 7 people, of which 46%) spend less than 8 hours/day, and 54% more than 8 hours per day. Table 3 shows the competencies of SRHS providers. About half (58%) of respondents declared having received essential training; 73.4% beneficiated from continuous learning; 77.8% learned about confidentiality on services. More than 90% of respondents found themselves friendly, respectful, excellent listeners, and nonpartisan workers. Table 4 shows some elements of the quality management of confidentiality.
Table 2: Percentage of staff and time hours spent on SRHS per district
Workplace
|
Respondents
|
|
|
N
|
%
|
|
Musanze
|
13
|
8.1
|
|
Huye
|
9
|
5.6
|
|
Rubavu
|
16
|
10.0
|
|
Rwamagana
|
16
|
10.0
|
|
Gasabo
|
30
|
18.8
|
|
Nyarugenge
|
46
|
28.8
|
|
Kicukiro
|
28
|
17.5
|
Affiliation
|
|
|
|
Government
|
66
|
41.3
|
|
Private
|
90
|
56.3
|
|
Religious
|
3
|
1.9
|
Total
|
|
159
|
100
|
Table 3: Staff characteristics and competencies in SRH service provision
Measurement outcomes
|
Total
|
Yes
|
|
No
|
|
|
N
|
N
|
%
|
N
|
%
|
Health care providers receive essential training
|
157
|
91
|
58
|
66
|
42
|
Use of written guideline
|
154
|
49
|
31.8
|
105
|
68.2
|
Continuous learning
|
158
|
116
|
73.4
|
42
|
26.6
|
Staff oriented to provide confidential AFS
|
158
|
123
|
77.8
|
35
|
22.2
|
Staff are non-judgmental, friendly, welcoming, good listeners
|
157
|
149
|
94.3
|
8
|
5.1
|
Staff demonstrate respect when interacting with adolescents
|
155
|
144
|
92.3
|
11
|
7.1
|
Table 4: Management of Confidentiality at health facilities
Services
|
Total N
|
Yes
|
|
No
|
|
|
|
N
|
%
|
N
|
%
|
Discreet entrance
|
157
|
56
|
35.7
|
101
|
64.3
|
Privacy in services provision
|
156
|
148
|
94.9
|
8
|
5.1
|
Confidentiality in accessibility
|
156
|
98
|
62.8
|
58
|
37.2
|
Privacy of the rooms
|
157
|
139
|
88.5
|
18
|
11.5
|
Comfortable waiting area
|
158
|
127
|
80.4
|
31
|
19.6
|
Availability and accessibility of services
Table 5 presents the available services related to HIV and STDs themes. STDs testing is available in 92.3% of facilities, but only 64.8% of health facilities surveyed give treatment HIV testing is available in 86.2% of facilities, but self-testing and self-testing kits were available in only 25% and 19.7% of facilities. However, only 42% of facilities give HIV treatment on the same day of diagnosis or 32.6% facilities in general. More than 80% of facilities offer HIV-counseling, and 64.2% practice circumcision.
Table 5: HIV related SRHS Available at the surveyed health facilities
Variable
|
Total N
|
Available
|
|
|
N
|
Valid %
|
STDs testing
|
159
|
145
|
91.2
|
STDs treatment
|
159
|
103
|
64.8
|
HIV testing
|
159
|
137
|
86.2
|
HIV self-testing
|
156
|
39
|
25.0
|
HIV Self-testing kits
|
157
|
31
|
19.7
|
HIV same-day therapy initiation
|
157
|
66
|
42.0
|
HIV treatment
|
158
|
50
|
31.6
|
HIV counselling
|
158
|
127
|
80.4
|
Circumcision
|
159
|
102
|
64.2
|
Table 6 presents the available services related to family planning. In general, 85.5% of facilities may offer contraceptive methods, including combined oral pills( 78.3%), progesterone pills (75.5%), the male condoms (73.6%), female emergency contraceptives (63.9%), Depo-Provera injection (66%), the implant (53.6%), IUD (49%), female condom (21%), lubricants (14.1%), vasectomy (11.5%), and tubule ligation (21.8%). Fertility awareness, antenatal counseling, and postnatal care may be available in 45-52% of facilities.
Table 6: HIV related SRHS Available at the surveyed health facilities
Family planning Services
|
Total
|
Available
|
|
|
N
|
N
|
%
|
Contraceptives
|
159
|
136
|
85.5
|
Combined oral contraceptive
|
157
|
123
|
78.3
|
Progesterone contraceptive
|
155
|
117
|
75.5
|
Emergency contraception
|
158
|
101
|
63.9
|
Depo Provera injection
|
150
|
99
|
66.0
|
Implant
|
153
|
82
|
53.6
|
IUD
|
155
|
76
|
49.0
|
Male condom
|
159
|
117
|
73.6
|
Female condoms
|
157
|
33
|
21.0
|
Lubricants
|
156
|
22
|
14.1
|
Vasectomy
|
157
|
18
|
11.5
|
Tubal ligation
|
156
|
34
|
21.8
|
Fertility awareness
|
158
|
82
|
51.9
|
Antenatal counselling (ANC )
|
157
|
75
|
47.8
|
Post-natal care
|
157
|
70
|
44.6
|
Youth-friendly services related to education and information and involvement of adolescents
Table 7 demonstrates the extent and quality of knowledge and information provided alongside HIV and Family planning issues.
Table 7: Information on SRHS at the surveyed facilities
Information accessible
|
Total N
|
Accessible N %
|
More information provided on services provided
|
159
|
150
|
94.3
|
More information on general health
|
154
|
132
|
85.7
|
Time for interaction
|
155
|
92
|
59.4
|
Referral mechanism
|
159
|
123
|
77.4
|
Job description and responsibilities
|
147
|
69
|
46.9
|
Info spread on services
|
158
|
98
|
62
|
Staff supervisor
|
156
|
62
|
39.7
|
Time for results provision
|
157
|
148
|
94.3
|
Non-discrimination in terms of educational materials
|
157
|
64
|
40.8
|
Non-discrimination in terms of service provision
|
158
|
107
|
67.7
|
Involvement in Feedback provision
|
159
|
86
|
54.1
|
Involvement in the availability of peer educators
|
159
|
53
|
33.3
|
Involvement in designing the feedback mechanism
|
158
|
67
|
42.1
|
Barriers and obstacles to access services
Table 8 gives multiple factors that can impact on the accessibility and quality services. Only 5% of the respondents could not list any barriers. Only half of the adolescents have their needs completely satisfied, meaning the other half encounter some obstacles to access the services available. The most significant obstacles come from a family interdiction (68.2%), Religion (65%), suitable operating time (78.3%), access to medical records (91.1%).
Table 8. Barriers or obstacles to access services
Any Barriers to SRHS
|
Total N
|
N
|
%
|
None
|
157
|
8
|
5.1
|
Needs of adolescents satisfied
|
156
|
79
|
50.6
|
Community
|
157
|
71
|
45.2
|
Family
|
157
|
107
|
68.2
|
Friends
|
157
|
27
|
17.2
|
SRHS staff
|
157
|
23
|
14.6
|
Adolescents
|
157
|
16
|
10.2
|
Policymakers
|
157
|
16
|
10.2
|
Religious beliefs
|
157
|
102
|
65
|
Social media usage
|
155
|
31
|
20
|
Waiting time
|
156
|
93
|
59.6
|
Service cost
|
155
|
80
|
51.6
|
Suitable operational hours
|
157
|
123
|
78.3
|
Access to medical records
|
158
|
144
|
91.1
|
Age at which young should access the service
|
96
|
48
|
50
|
Accessibility to location Less than 30 min
|
156
|
98
|
62.8
|
Accessibility in location 30 minutes-1 hours
|
156
|
53
|
34
|
Accessibility in location 1 hours-2 hours
|
156
|
5
|
3.2
|
Qualitative data
About availability of SRH services for adolescents
In-depth interviewees agree with the descriptive quantitative data, saying the majority of SRH services are available at the health facilities. Surprisingly, they mentioned that some of their products and services made available are often under-utilized, end-up expired, which leads to wastage of scarce health resources.
“The male’s condoms are available, but there is the stock-out of the female’s condoms. The previous females’ condoms expired because the clients did not request them. The females say that they do not use female condoms because of the difficulty with the insertion of during sex. The participants also do not like using them because of the difficulties in using them during sexual intercourse” — nurse _in Gasabo District.
We also aimed to document the package of SRH services available at health facilities, and the respondents expressed that some services are not available at their facilities, due to the predetermined SRH health care package for health facilities that are set by the Ministry of Health guidelines. The respondents feel that if they were allowed to provide some services in their health facility, they would have had all the SRH services needed by the adolescents.
“This private institution provides the tests and treatments of STIs such as Syphilis, Trichomoniasis, Candidiasis, Chancroid. It also provides HIV counseling. For HIV treatments, HIV patients are transferred to public institutions for ART. We also have some contraceptive methods, but people who need family planning are also transferred to the hospital or health center where the governmental institutions provide these services for free. Moreover, pregnant women in our institution are cared for, for example, on echography, ANC and PNC care, and partial health interventions are provided. The challenge at our facility is a lack of rights to deliver all the SRH services, but we need to create a strong partnership with the Ministry of Health for us to provide them. A medical doctor at a private clinic_Kicukiro.
Accessibility of SRH Services to adolescents
The majority of the respondents expressed that their facilities have been providing more information on SRH services 94.3% and general health 85.7% after they have provided a specific SRH service to an adolescent. (59.4%) respondents only reported that they provided more time for interaction with adolescents, whereby also few staff had a job description to guide SRH services provision to adolescents 46.9%.
In-depth interviews show that interviewees were providing information on the availability of SRH services and their location to adolescents but not on a routine basis. SRH Services providers felt that all the required information by the adolescents on SRH services are made available when they are ongoing campaigns organized by different institutions.
“Health providers spread the awareness about available friendly Adolescents’ SRH services; when there is the campaign because adolescents attend it”. Nurse_ Huye.
The interviewees also lamented being over-worked with other health care services while providing SRH services. They are scared that the lack of detailed information about their responsibility at work affects the time spent providing such services to adolescents.
“No organogram presents here because we have other responsibilities within other units or departments…………” Nurse _Gasabo.
Table 4 shows that the service providers believe that only 62.8% of the adolescents use less than 30 minutes walking distance to reach the venue for accessing SRH services, while the use of social media for education and information provision on SRH, were not commonly used 72.2% by the health facilities. Respondents feel that close to half of the services are provided at a low cost 51.6% and almost half of the study respondents reported that the needs of the adolescents were not being met in their facilities 49.4%. Furthermore, most of the study respondents responded that they do not provide SRH information to adolescents through social media platforms like Facebook, Whatsapp, and Twitter.
“Social media are not used at the health center because our health center still has the barriers to having required equipment and resources needed for providing the education and information using the social media platforms……………….. ” Midwife _Rubavu.
The respondents believed that it is only at public facilities that adolescents can access SRH services at an average cost. They further said that for those who had access to any medical insurance, access to services is at a price worth seeking for them again.
“The services are provided at low cost, and the moderator ticket is paid by those who have health insurance. The patient with no health insurance must pay 100% of the treatments,”, Nurse _Nyarugenge. “Our institution provides various services for private clients, that is why the services we provide, including SRH services for adolescents, are paid 100%, but we accept the health insurance when it is relevant” Nurse _Rwamagana.
Quality of SRH Services provided to adolescents
Tables 5, 6, and 7, demonstrate the perceived quality of SRH services by services providers provided to adolescents within the urban health facilities in Rwanda. In table 5, it was found that health facilities did not separate entrance for adolescents to use while they visit the health facility to access SRH services 64.3%, but respondents expressed that health facilities have private rooms for consultations 88.5%.
“The providers give SRH services to adolescents in privacy and confidential manners. The socio-demographic and patients’ status are kept in privacy.” Medical Doctor _Musanze.
Table 6 shows that 68.2% of respondents did not present to the interviewer any written guidelines used for SRH services provided to adolescents. Additionally, the respondents felt that only 58.0% had accessed some training on providing SRH services to adolescents, while only 73% had continuous access to adolescent SRH education. They added, however, that in-service training and documentation are conducted to provide services to adolescents, whereby they said that they provide SRH services adolescents without any prejudices and stigmatization and that room for improvement is needed.
“The clinic does not have a trained health provider about the SRH services and there is no specific health provider for adolescents seeking SRH services” Nurse _Rubavu. “The staff involve themselves in the continuous learning and online courses”. Nurse _Gasabo. “Although the clients are received without judgment, well welcoming and respectful manners, there is a need for more efforts especially counseling where some fear about coming to seek for the services”. Social worker_Huye.
Table 7 reported adolescent involvement in services provision. A total of 45.9% respondents said that they do not have formal mechanisms to receive feedback from the adolescents on services provided, and only 57.2% of respondents acknowledged to involve adolescents in designing the feedback mechanisms, while only 33.3% of the facilities make use of the adolescents peer educators in SRH services and information provision to adolescents. Respondents expressed respect for privacy and confidentiality while providing SRH services to adolescents.
The respondents said that adolescents do not have a suitable means to provide feedback on the services being provided. This is coupled with the fact that they are less involved in suggesting ideas towards the services that should be provided to them. These made the respondents feel that the sexual and reproductive health needs of adolescents might not be met in several facilities. “There is no transparent and confidential mechanism for adolescents to submit complaints or feedback about SRH services at the facility, but the adolescents receive results or feedback from the services delivered”. Nurse _Huye.
“The peer’s educator or counselors are not involved in the SRH services offered to adolescents. There is no well-organized system to receive and provide SRH care to adolescents by peers. The SRH department is not active/operative because of the lack of resources. Therefore, the people who were peer educators or peer counselors among adolescents are no longer working. Almost all of the adolescents who were in charge are students. Besides, most of the adolescents in the area surrounding this health center are the students who become available on the weekend and holidays” Nurse _Musanze.
Respondents added that the adolescents' needs are not being met within most of the facilities “The needs of adolescents seeking for SRH services are not met at the health center because the services are not specific and there are insufficient resources including equipment materials, medical drugs, tests and insufficient providers” Nurse_Rubavu.
Barriers to SRH Services accessibility and provision to adolescents
This study also documented the obstacles that the SRH service providers perceive to limiting seeking to access SRH services for adolescents. Table 8 shows perceived barriers by SRH service providers that adolescents face while seeking for SRH services. Major obstacles that interviewed health providers recognized were religious leaders, 65.0% and family members 68.2% limiting adolescents to request or access the SRH services. The in-depth interview states that the respondents’ efforts to provide adolescents with SRH services are often shattered by either religious members, community members, policies in place, and family members that limit access or seeking behaviors by adolescents.
“The facility faces challenges including the community, family and religious leaders who influences SRH services seeking by adolescents at the facility”. Midwife _Gasabo.
Respondents added that “The barriers happen at our health facility because of the cultural influence, religious determinants. For example, church leaders do not accept family planning and circumcision. These barriers increase the rate of low accessibility to SRH services at the health center”. Social worker_Ruvabu