Participants Social Demographic Characteristics and Awareness of SRH Services Provided at Health facilities
A total of 121 adolescents from selected cities were enrolled in this study. The results indicated that the majority (38.8%) of the study participants were aged 15 to 17 years and females made (62.8%). Regarding the education level of adolescents, the majority 46(38%) had primary education level, and ordinary level of secondary school 43(35.5%) [Table 1].
Among 120 adolescents who responded, 105(86.8%) participants were aware that sexual and reproductive health (SRH) were provided at health facilities in Rwanda. The results indicated that adolescents aged 18-19 were highly aware of SRH services 41% compared to other age groups of adolescents. Findings showed that the majority 62 (59%) of females were more aware of the SRH services provision than males 43 (41%). Of 105 (86.8%) adolescents who had awareness of the SRH services provision, majority (36.2%) of them were found to be studying in ordinary level of secondary school (Table 1).
Adolescents’ awareness on the availability of SRH services at health facilities
There are a variety of SRH services intended to be given at the health facility. We assessed the awareness of participants on availability of the SRH services at nearby health facilities. Most adolescents reported to be aware of SRH services provided at health facilities, whereby the most known available services were circumcision and HIV testing [Table 2]
Utilisation of the sexual reproductive health services
Among 121 adolescents, only 42 (34.7%) used some of these services while the remaining 79 (65.3%) did not use the SRH services. The results indicated that among the services utilised by the adolescents, HIV was mostly used (18.2%), circumcision (0.83%), both circumcision and HIV testing (7.4%), HIV test and HIV testing and antenatal care (ANC) (0.8%) [Figure 1].
Qualitative results from in-depth interviews indicated that adolescents faced the barriers to SRH usage such as the limited awareness and poor information or insufficient knowledge about the SRH availability and the health facilities which provided these services. These barriers remain problematic among adolescents in need of them. Adolescents highlighted that they utilized particular SRH service due to their previous awareness of it or during massive community screenings such as during HIV Screening.
“I am aware of my HIV status because I was tested when I was going to receive a transfusion at a hospital” (Female participant, Rwamagana).
Some adolescents responded that seeking SRH services at the health facilities is not possible for them, but they access the SRH services during occasions such as when there are the campaigns organized on particular SRH services, such as HIV testing or VMMC. A 25-year-old male explained:
“We sometimes access the services, once they are testing for HIV during campaigns in our community”
Many adolescents mentioned their reason for not utilizing SRH to be associated with not being informed. The adolescents indicated that the concern that affects their access to SRH services was lack of real information that resulted to low utilization of the SRH services at youth centers and health facilities:
“We are not aware of the services available for us, no information given to use, and lack of knowledge on why to seek such services prevent some of us from accessing the SRH services” (Female participant, Musanze).
Some adolescents who participated in this study expressed that all of them should utilize these SRH services, especially girls.
“Girls must know those services and be aware of their sexual health as they are the ones who face too much consequences” (Female participant, Kicukiro)
The results indicate that most adolescents from the six selected cities confirmed that the walking distance to the health facilities to access SRH services is less than 30 minutes. However, 6(5.2%) reported that those services are located too far from them, and that this hinders accessibility because of the long distance it takes to reach the health facilities. Majority of adolescents 104(90.4%) did not use media channels for getting information regarding SRH and SRH services provided in the living settings. Accessibility to medical records, and suitability of the daily operating hours were found with 92.3% for each [Table 3].
The qualitative data from the interviewed adolescents are like the quantifiable results. The qualitative data highlighted that socio-cultural and geographical constraints were the barriers which negatively affected their accessibility to SRH services. It was, therefore, found that misinformation and poor information related to the service delivery was the barrier:
“I do not use social media for getting information regarding SRH services. We get false information from colleagues, and it is sometimes difficult to be informed of the places where we can find reliable information on SRH services accessibility” (Male participant; Gasabo).
Adolescents’ experiences suggest that health care providers rendering SRH services to them were willing to avail their medical history to adolescents whereby 24(92.3%) accessed them freely, and 23(76.67%) did not miss any service they needed:
“Yes; sometimes when I request more information on my SRH medical history, it is provided easily”. (Male participant, Rwamagana).
It was also revealed that some SRH resources are not available at the health facilities. Some interviewed adolescents admitted that condoms are available for males, while female condoms are not available in health facilities.
“No; male condoms are easily accessible and available but female condoms are not there (Female participant, Musanze)”
Adolescents perceptions on administrative procedure while accessing SRH services
The results indicated that 96.2% of the services are provided free of charge and 92.3% of adolescents reported that the services are delivered at a suitable period of the time, however, the majority (66.6%) reported lack of staff members to oversee ASRH services. Adolescents showed that they spend little time waiting for the services. However, 3.9% stated that they wait for over one hour to be given the SRH service at the health facility [Table 3]. While it is likely that utilising health insurance addresses the problems related to high service cost when seeking SRH services, some adolescents mentioned that in private health facilities, the cost of SRH services is not favorable for them.
“The cost of circumcision is high within the private health facilities, I paid more than 10,000 Rwandan francs” (Male participant, Gasabo).
Confidentiality and privacy
The results demonstrate that close to half of the health facilities still provide SRH services in the same room for both Adolescents and adults. About 12(46.2%) of adolescents who at least used the SRH services stated that the health facilities in charge of providing the services had not comfortable rooms or separated rooms for delivering the SRH services to the adolescents. The adolescents thought about what adults would think of them once they saw them looking for SRH services. 29(92.6%) of participants who used the services accepted that they are not asked for guardian permission [Table 4].
“We are able to utilize or access the SRH services at health facilities without parent/guardian consent because everyone enters alone in the rooms of service providers” (Female participant, Gasabo).
The interviewed adolescents also reported the difficulties of having a desired waiting space while waiting for access to the SRH services delivery (14.8%). Moreover, some adolescents had witnessed that some facilities have comfortable waiting spaces at the SRH services department (85.2%). Adolescents’ friendly services were said to be more accessible in youth friendly centers and are the main one that were reported to provide educational materials to adolescents.
“At Dushishoze [a youth friendly health center], they provide books and articles on SRH information and services such that you can even carry them at home.” (Male participant, Huye).
Staff characteristics and youth involvement in the services provided to the adolescents
The findings showed that all the adolescents that the staff of the health facilities that offer SRH services among the adolescents were knowledgeable that the SRH services were friendly provided (74.1%), but only close to half of adolescents indicated that 62.07% of the health providers spent the extra-time to provide the adequate services to the adolescents. It was found that only 50% of health providers delivered to the adolescents general information on health during SRH services provision Majority (74.1%) of the interviewed adolescents revealed that the staff of the health facility provided the SRH services to them with no judgment but friendly and appreciable welcoming, however, 25.9% of the adolescents reported that the health providers did not provide the SRH services friendly and adequately to the adolescents. Findings indicated that a half of health providers provide essential information on health and 92.6% of health providers provided to the adolescents SRH services with respect [Table 5].
The results demonstrated that the involvement of the adolescents in the SRH services they need remains low. To involve peer educators in the services was low (18.5%), and involvement of adolescents in designing the feedback mechanism was 19.2% while availability of transparent and confidential mechanism for complaints about SRH services was 48% . Qualitative data confirmed that health services providers provide effective SRH services to adolescents.
“Sometimes when making conversations with SRH services providers, you realize that they are knowledgeable” (Male participant, Rubavu).
“Looking into the way a service provider informs and responds to my questions, shows me that she is knowledgeable” (Female adolescent, Rwamagana).
The staff professional attitude was described by the respondents and the majority of the adolescents’ said that providers gave them more information on the SRH services they have offered to them:
“Before and after circumcision they teach the importance of circumcision and that it does not prevent HIV at 100%” (Male participant, Huye).
The study explored the involvement of adolescents with SRH provision to their peers and in the overall provision of services, and young people are not available at 22(81.5%) as peer educators or counsellors at urban health facilities where adolescents attend for SRH services.
“There are only older people who provide us SRH services (Male participant, Rwamagana)
“I have seen that the majority of those who provide SRH services and information are possibly over than 30 years old “(Male participant, Gasabo)
The results from the adolescents indicated that 21(80.77%) respondents reported the absence of adolescents’ involvement in designing feedback mechanisms and 13(52%) respondents pointed out the lack of transparent mechanisms to give complaints or demonstrate dissatisfaction . The qualitative results presented that the adolescents are not involved in that they should be provided and availability of various opportunities that help them to access SRH services remained the concern. They also indicated that they lack the opportunities that should help them to increase SRH awareness, positive perceptions, and effective utilization of the resources:
“We do not receive an open opportunity to give and provide ideas on the sort of services they should give us [adolescents]” (Female participant, Huye).
The study has also shown that some adolescents did not have any information on the age at which they are allowed to access these SRH services or if they are actually supposed to use those services. Majority of the adolescents who were participants in this study believe that only adults are supposed to use the SRH services or at least a menstruating adolescent can be allowed to access the SRH services.
“I think to be allowed to access the SRH services, adolescents should be 15 years old because she knows what he or she is doing at that age” (Male participant, Rubavu).
“We can be allowed to access and utilize the SRH services at 12years old because most of at that age, adolescents start menstruation.” (Female participant, Kigali).
Barriers to SRH services accessibility for adolescents
Interviewed adolescents also mentioned various barriers such as: lack of information about comprehensive SRH services for adolescents and where they can be accessed, community-stigma surrounding accessibility to SRH services, unaffordable services within private health facilities ,fearing parents and church leaders on what they might think about adolescents who try to utilize or request SRH services and judgmental attitudes of some health service providers.
Our findings communicate that there are people influencing adolescents’ poor utilisation of SRH services. Adolescents were asked about their experienced perceptions about community members, family members, friends, religious leaders, among others on their influence toward utilizing or not utilizing the SRH services for adolescents. Our results demonstrate that the family members occupied the highest position of people 53 (44.9%) who limit access to SRH services for adolescents, followed by community members 36 (30.5%) and religious leaders 34 (28.8%) coming third on the list of people who limit access or utilization of SRH services for adolescents in urban settings of Rwanda. This might affect the accessibility to SRH services because adolescents were afraid, had self and social stigma from community in looking for the SRH services:
“Community members limit adolescents’ access to SRH services because they may gossip about you, we also fear them, and being ashamed if they saw me accessing those services, and therefore, I do not want them to know that I utilize SRH services” (Female participant, Kicukiro).
Adolescents indicated that the health care providers have a positive attitude of SRH that help them to provide for the adolescents with confidentiality and respect the SRH services. An adolescent said:
“Health care provider for us in confidential manner and privacy because everyone gets results alone”
The adolescents highlighted that the inaccessibility to SRH services was due to lack of privacy, confidentiality and equipment of health facilities. These attitudes caused them not to go seeking health care services at the health facilities nor discuss their SRH problems. A participant said:
“The services like circumcision is done during military week where more than one adolescent enters the room.” Another expressed.
In addition to that, the results indicated that the negative attitudes of the family members challenged them to access the SRH services. For instance; the family relatives and parents limited adolescents, spreading wrong and/or confidential information related to the services provided:
“Community members such as neighbors may spread the information to others while I did this in a private way to limit people who knows what I do in relation to sex issues and SRH in general”. (Female participant, Kigali)
“Family members often limit us to access SRH services because this is linked to being a bad child or to having bad manners if it is known that you want or access SRH services”. (Male participant, Huye)
“Family members limit us to access SRH services. I cannot try to access or request such a service if there someone who knows me around because they will spread rumors in my family that I am pregnant or that I am a prostitute” said a female adolescent from Kigali.
The qualitative findings indicated that socio-cultural norms constitute the important barrier to access SRH services where the religious leaders limit the adolescents for using SRH services. The findings demonstrated that the religious beliefs were an important contributing factor to the low access to SRH services:
“Religious leaders are the principal people who limit me to access the SRH services because they are refusing service utilization in general” (Male participant, Rubavu).
Another participant explained:
“Religious leaders prevent me to access and utilize SRH services because they will send me outside of the church and therefore, I do not even try to buy a condom from a nearby shop to prevent people from telling our pastors and other church leaders” (Female participant, Rubavu).