Socio-demographic characteristics of participants
A total of 12 providers were participated in the study. The ages of participants ranged from 22 to 49 years old with the mean age of 32.5 years old. One health professional from sexual and reproductive health unit of the city administration; three health professionals serving at youth friendly sexual and reproductive health services; one high school club coordinators; two urban health extension workers; one coordinator of health posts found in the city; two counselors working at youth centers, and two representatives of adolescents who have experience of participating in reproductive health related clubs were participated in the study as a key informant interviewees. [INSERT Table 1 HERE]
Table 1
Socio-demographic characteristics of study participants, Hossana Town, Hadiya Zone, Ethiopia, March 2020 (n = 12)
Characteristics | Frequency |
Sex | |
Female | 5 |
Male | 7 |
Age | |
20–35 | 9 |
36–50 | 3 |
Religion | |
Protestant | 10 |
Orthodox | 1 |
Catholic | 1 |
Occupation | |
Clinical Nurse | 4 |
Public health officer | 2 |
Clinical Nurse +UHEWs | 2 |
Psychology | 1 |
Sociology | 1 |
College student | 2 |
Educational status | |
Degree | 8 |
Diploma(10 + 4) | 2 |
Student | 2 |
Experience in years at AYFSRHs and related centres | |
1–9 | 9 |
10 or more | 3 |
Emergent themes and subthemes
Barriers to using adolescent and youth friendly sexual and reproductive services were addressed to service providers’ point of view. Five themes were identified in the data: provider, health facility, adolescents, community, and health system level barriers. These themes were emerged as a result of coding and categorizing participants’ responses to questions addressing adolescents’ barriers not to accessing AYFSRH services. Some of the quotes are illustrated from the corresponding codes in each emergent theme and subtheme [INSERT Table 2 HERE].
Table 2
Themes, subthemes and some illustrative quotes indicating barriers to using adolescent and youth friendly sexual and reproductive health services, Hossana Town, Sothern Ethiopia.
Themes | Subthemes | Sample codes | Sample illustrative quotes |
Provider level barriers | Poor providers’ competency | Providers lack knowledge | […] I was very much confused. I tried to […] […] worry about of HIV /AIDS but, for pregnancy. Pharmacies […]If I had understood his feeling, I would have helped him […] |
Negative attitude | […]Challenges! I face problem when educating female servants […] |
Providers lack communication | […]“Are you expecting me to say just I am going to eat it? [..] […] providers often do not use direct language […] |
Confidentiality breach, disrespect and discrimination | Provider breach confidentiality | […] problem of keeping confidentiality of adolescents’ sexual […] […] I will tell his secrete to his family […] […] professionals. There are also problems of confidentiality […] |
Providers choose service | […] once, I don’t let them to take again. I counsel them to […] |
Provider discriminate by sex | […] facilities to seeking help for STI problem. Unfortunately […] |
Providers' lack of follow up | Providers lack follow up | [..] the service. I referred but I don’t know the final fate […] |
Adolescent level barriers | Preference to seeking care and peer influence | Adolescents resist advices | […] But, they [Adolescents] don’t want to do this [ sexual abstinence]” |
Decision influenced by peers | […] I see that adolescents are influenced by peers. […] |
Financial constraints | Adolescents lack money | […] dependent on family income. They lack transportation cost […] |
Lack of information and attitude towards SRHs | Adolescents lack knowledge | […] adolescents don’t have awareness about sexual and […] |
Adolescents lack attitude | [..]Many adolescents developed low perceived risk of severity […] |
Fear to violation of confidentiality and cultural taboos | Adolescents fear confidentiality breach | […] …adolescents are afraid of violating privacy and confidentiality […] |
Adolescents fear providers | […] They felt fear and shame […] |
Health facility level barriers | Lack of supply and unsupportive environment | Shortage of supplies | […] many resources and supplies required to provide the services. […] |
No entertainment | […] can’t say that “youth friendly sexual and reproductive […] |
Adolescents lack privacy | […] private and confidential services. Adolescents fear others […] |
Inadequate trained staff and training | Shortage of trained providers | […] We intentionally placed the clinic […] |
Lack training for providers | […]Health extension workers like me should be trained on SRHs. […] |
Long waiting time and inconvenient working hours | Long waiting time | [..] I assure you that waiting time is very high because we […] |
Community level barriers | Community ‘s bad attitude and lack information | Poor community awareness | […] centers are considered rude, but those who enter the church are considered polite by a church person […] |
Community negative attitude | […] are rude but those who got to church are considered polite […] |
Lack of parental and social support to adolescents | Parents lack discussion | […]Parents don’t talk about sexual and […] |
Church lack discussion | […] settings especially in “Adar program”. Majority of church […] |
Inadequate support to schools and youth centers | Teachers lack help | […] cultures/ taboos. They [teachers] don’t counsel students to go to such […] |
Youth centers closed | […] attention for such activities. Clubs in the school are not […] |
Inadequate literacy of sexual health | Lack of curriculum | I suggest that curriculum should be designed and educate […] |
Presence of unauthorized providers | Unauthorized providers | […] they don’t want to go to healthcare facilities for […] |
Health system level barriers | Poor implementation | Government lack commitment | [..] Ehh ! I observe that unemployment is a challenge for not […] […] services. This was more effectively done when we were [..] |
Strategy don't address need | [..] and reproductive health needs of adolescents? I think that […] |
Poor multi-sectorial engagement | Lack of multi sectorial collaboration | […] institutions like women, children and youth affairs do not […] |
Theme 1: Provider Level Barriers
Based on this theme, healthcare providers gave personal and collegial experiences that restricted adolescents from accessing existing services. Three subthemes were emerged: poor provider competency; adolescents’ confidentiality breaches, disrespect and discrimination of adolescents; and lack of provider follow up.
Subtheme 1.1: Poor provider competency
Under this subtheme, participants discussed the knowledge, attitudes, communication, and technical skills gaps of healthcare providers including themselves in performing critical tasks that may prevent adolescents from using sexual and reproductive health services.
One of the participants in the study, who works at a specialized youth center, noted the knowledge gap as:
“A male adolescent with a special need came to me. I was not familiar with it. [...] He asked me what problems he may face if he continues to practices “masturbation”. Instead of having sex with a female, he wanted to orgasm himself. I was very much confused. I tried to advice what I perceive.[…] What I want to underscore here is that we [health care providers] should understand holistic sexual health practice of adolescents. If I failed to help him, he will not revisit the center. [Female, Age
20–35, Clinical Nurse]
Another participant added what his friend had said.
“My friend is a health professional. He told me that many adolescent girls took family planning injection and went for sex. They [adolescents] don’t worry about of HIV /AIDS but, for pregnancy. Pharmacists inject family planning for adolescents of about 13 or 14 years old. Private clinics also do the same thing. […] I don’t know. Don’t these healthcare providers know this risk? [Male, Age
20–35, Psychology]
Urban health extension workers themselves and other participants realized that they did not have enough knowledge to teach students at school and others at outreach activities about sexual and reproductive health. One of the health extension workers reflected her knowledge and attitude towards educating adolescents about sexual health as:
“[…] I invite other health professionals to provide health education there [school].[…] Parents should help their children through praying.[…] I face problem when educating female servants and commercial sex workers[..]” [Female, Age
20–35, Health extension worker]
Nine out of 12 participants felt that the communication between providers and adolescent clients was influenced by a number of factors, including cultural factors. Majority of the participants felt that for various reasons, adolescents did not talk openly to providers about sexual health problems. This in turn prevented them from using SRH services. According to one of the participants,
“I saw a 10-year-old boy. He went to our [center] condom outlet box. I suspected he was going to the game center. But, he picked up a packet of condoms and kept in his pocket. I was shocked and asked why. He replied to me as “Are you expecting me to say just I am going to eat it?. If I had understood his feeling, I would have helped him in the first place. That was my problem.” [Female, Age
20–35, Clinical Nurse]
Another more experienced participant sated communication barriers as:
“Adolescents want everything about sexual health to be transparently talked about in their mood. They would like the media to speak openly. We (health professionals) need to talk openly with adolescents. However, providers often do not use direct language. They don’t counsel adolescents with joking and loving. For example, most professionals use “ sexual intercourse ” [Amharic: Yegibre Siga Gingnunet] while counseling adolescents. What does it mean for adolescents?.” [Female, Age :36–50, Clinical Nurse]
The researcher's observation also confirmed that other health workers did not have the knowledge or positive attitude towards youth-friendly services. During the interview, the investigator observed that other health care providers were disturbing both counselors and adolescents (moving in and out for their own purposes). This phenomenon was common in almost all health facilities, with the exception of one specialized youth sexual and reproductive health center.
Subtheme 1.2: Confidentiality breach, disrespect and discrimination of adolescents
This subtheme discussed participants’ own or colleague’s experiences of breaching confidentiality as barriers to accessing sexual and reproductive health services. The subtheme also explained disrespect, and discriminant behavior of healthcare providers.
One of the participants explained how she was breaching confidentiality as:
“If a 15 year- old boy wants to have sexual partner, I will tell his secrete to his family. Because, I see that adolescents are influenced by peers not by theirs own decision.” [Female, Age: 20–35, Health Extension]
Another participant witnessed disclosing secrecy of adolescents from his experience.
“Healthcare providers have a problem of keeping secrets about adolescent and sexual issues. Let me give you an example that makes me angry. “A girl from school was attending phase-1 training on HIV / AIDS. She told a secret to the trainer (male health care providers). She told him that her families scheduled a female genital mutilation program. Instead of consulting and linking her with the right services, he disclosed her secrets to phase- II trainees. One of the attendees asked me who had been sent using key identifiers told by the trainer. I called for a school head to know who she was. He told me her name. […] I don't know if it should be made public. I think this is a problem. ” [Male, Age
20–35, Psychology ]
One participant reflected discrimination made by healthcare providers regarding sex of adolescents
“Approximately, 17 or 18 year-old male adolescent told me a hurting story. He went to health facilities to seeking help for STI problem. Unfortunately, the healthcare provider was a female. She told him that he couldn’t get the service because a male provider was not around. So, she let him go to another private clinic. Like this teenager, many others may not want to visit such healthcare services. […] Many healthcare providers believed that a condom demonstration for male adolescents should be done by a male care provider.[…]” [Female, Age
20–35, Clinical Nurse]
One participant also shared his experience as a sign of disrespecting adolescents
“I have often noticed that private health care providers work for money rather than providing adolescent friendly services. I heard that they inject Depo (Family Planning Method) for girls aged 14 and 15 without asking why those girls came to the clinic. In addition, most private health care providers perform abortions without proper counseling and without looking at other options. [Male, Age
20–35, Psychology ]
Subtheme 1.3: Providers' lack of follow up
This subtheme explained that providers' lack of follow up is an obstacle to accessing sexual and reproductive health services. Majority of health care providers reported that they would not follow adolescents once they had served.
One of the participants described the follow up problem as:
“They were both students between 15 to 16 years old. I sent them to a private clinic for an abortion. I know they didn't have money for the service. I referred, but I didn’t know their fate. I didn't know where they went for such a problem. In such cases, adolescents will never visit the facility again.” [Female, Age
20–35, Clinical Nurse]
The youth's sexual and reproductive service coordinator also said that trained peers did not follow their friends.
“We [Youth Association Center] trained peers. Each peer is expected to network up to 10 teenagers. They graduate every three years and other new groups continued to be trained. We have streamlined the process. Accordingly, peers perform their duty anywhere outside the center.” [Male, Age
20–35, Psychology]
One participant from the City Administration's Sexual and Reproductive Health Unit stated the follow up gap as:
“Previously, we (City Administration Health Office) have provided supplies and equipment (educational materials, musical instruments, loudspeakers and other necessary equipment) to the youth center. These devices were stolen. I don't know how. We asked Office of Women, Children and Youth by an official letter to explain how it happened and how to prevent it. Now this youth center stopped its function. There are other youth centers that have stopped working for similar reasons. But we found nothing.” [Male, Age: 36–50, Clinical Nurse]
Theme 2: Adolescent Level Barriers
This theme was emerged from health care providers’ and their colleagues challenge that prevents adolescents from accessing friendly sexual and reproductive health services. Four sub-themes were emerged from this theme: fear to violation of confidentiality and cultural taboos, financial problems, care choices and peer pressure, of lack information and poor attitude towards the services.
Subtheme 2.1: Fear to violation of confidentiality and cultural taboos
Under this subtheme, major misunderstandings and legitimate breaches and fears due to cultural taboos are explored. Most health care providers reported that when adolescents visit youth clinics, they perceived that there is a lack of confidentiality and that they are afraid of being seen by other people. One of the participants gave an example of how adolescents were prevented from accessing nearby health care services.
“[…] Overcrowding in majority of our public health centers is not safe. As a result, adolescents are afraid of violating privacy and confidentiality. For example, I know some pregnant adolescents who went to abortions up to 32 kilometers to hide for fear of breach of confidentiality.” [Male, Age
20–35, Public health officer]
Another participant added:
“[…] A pregnant adolescent and her sexual met were not interested to be referred to government hospital for abortion. They felt fear and shame. They perceived that health care providers working in that government hospital may not accept them. [Female, Age
20–35, Clinical Nurse]
Subtheme 2.2: Lack of information and attitude towards SRHs
This theme discusses how health care providers faced challenges due to adolescents’ poor knowledge and attitudes about sexual and reproductive health services that prevented them from accessing the service. Accordingly, ten participants reported a gap in information for adolescents regarding sexual health and services ranging from not knowing where to go for seeking help to developing negative attitude towards the service.
One of the participants revealed that adolescents do not visit youth clinics as:
“Many teenagers often take post pills every morning at our clinic. […] I provide it to them. You know, they can get it from pharmacies if I refuse to do so. They have no access problem. They don’t worry about the side effects of post pills. Many teenagers fear pregnancy more than any other health risk. They do not pay attention to HIV / AIDS and other STIs. I do not know. Either they do not understand or there is a fear of pregnancy. ” [Female, Age
20–35, Clinical Nurse]
Participants gave a testimony that many adolescents had developed a negative attitude towards sexual health services. One of the key informants stated the problem as:
“Many adolescents developed low perceived risk of severity about sexually transmitted infections including HIV/AIDS. For example, I have heard many adolescents who reflect wrong perception. They [adolescents] reflected the incurable HIV/AIDS as if it was curable diseases like other STIs. […] It seems that they don’t want to listen to any counselor at all. School adolescents act like commercial workers. I can say that paradigm of sex commercialization is seemed to shift from poor women to students [adolescent]” [Male, Age: 20–35, Psychology]
Subtheme 2.3: Preference to seeking care and peer influence
This subtheme explains providers’ view about adolescents’ choice of care and influence of peers to seek and decide to use sexual and reproductive health services. Providers reported that adolescents seem to have concern on age and gender of healthcare providers to seek help to sexual and reproductive health services. Healthcare providers had considerable dialogues about whether gender-matched providers were most appropriate.
“I had experienced that many adolescents seek providers of similar sex. They perceived that a male adolescent who seeks help for STI [sexually transmitted infection] problem should be helped by a male care provider. […] It was for females too. I also prefer to male if I were male.” [Female, Age
20–35, Clinical Nurse]
Providers also reported that adolescents seemed to care about the age of healthcare providers to access sexual and reproductive health services. One participant stated:
“[…] If they [adolescents] missed me [older health care providers]; they try to search for other two female professionals who were working here for many years. The current problem is that adolescents don’t want to be served by adolescent health professionals. They feel like to be served by elders. I don’t know.”[Female, Age
36–50, Clinical Nurse]
Half of participants had had mentioned that adolescents were influenced by their peers in decision making of accessing sexual and reproductive health services. Majority of healthcare providers reported that peers provide health information and promote where and when youth friendly services were being provided.
Subtheme 2.4: Financial constraints
More than half of the interviewees testified that many adolescents were hindered by joblessness and access to household resources due to cost of service delivery, supplies, and transportation. Many adolescents often denied access to sexual and reproductive services even though few of adolescents have money to pay for services and supplies.
One of the interviewees indicated:
“Yea, many adolescents lived separately from their families for reasons such as education. They are dependent on family income. They lack transportation cost to come to the health facility for SRHs. They can’t afford lunch or tea cost while spending for a day.” [Male, Age
36–50, Public Health officer]
Another participant added to this important barrier to accessing SRH services.
“[…]. They [housemaids] have a right equivalently as other family members as possible. Maids are often considered diseased in fact they are considered to have been sexually abused by a family member. […] I have met many female maids who have been sexually abused by family members like male adolescents, household heads, neighbors and others. […]When maids get pregnant, employer(s) let them leave their home. Employer(s) don’t want to listen about household maids’ problems. You know, such maids may not have money to access any sexual health services. [Male, Age
20–35, Psychology]
Theme 3: Health Facility Level Barriers
This theme focused on the experiences of participants and their colleagues in facing challenges that may prevent adolescents from accessing existing services. Three subthemes were emerged: lack of supply and unsupported environment, inconvenient waiting and working time; and inadequately trained staff and training.
Subtheme 3.1: Lack of supply and unsupportive environment
This subtheme discusses providers’ experience on the lack of resources needed to perform key activities to meet the sexual and reproductive health needs of adolescents. On the other hand, barriers to responding to the needs of adolescents have been investigated. The majority of participants strongly pointed out the lack of supplies required to provide adequate and appropriate for adolescents. Lack of written instruction and lack of educational materials such as posters and flyers were also reported. One of the participants explained the problem:
“I counsel how to use family planning. Previously, all packages were here [Youth clinic]. In this unit, supplies were fully supported by IFPH [Non-governmental organization]. But now, there is no support. […] After IFHP phased out, there is a shortage of many resources and supplies required to provide the services. We (health professionals) sometimes do not have some long-term family planning methods, HGG (pregnancy test) and STI medicines. [Female, Age
36–50, Clinical nurse ]
Providers cited inadequate physical space and privacy as institution-level barrier to using adolescent health services. The service providers also pointed out that youth clinics do not have enough entertainment and spaces. The researcher’s observation during the interview also proved that all youth clinics have only a single unit and is not separated from adult centers. Some centers were also close to HIV/AIDS clinics.
Most participants agreed that the lack of privacy in health facilities and hospitals may be resulted fear of being seen by friends, relatives, or the community. One of the participants described the situation as :
“[…] An auditor and a counselor share a similar room. An auditor gets out from the room when clients come and comeback when clients leave a room. In this case, the service itself is not youth friendly at all. I think this is unsafe even for adults. Adolescents need private and confidential services. Adolescents fear others and feel shame if they are seen by others. They don’t revisit such centers.” [Male, Age
36–50, Clinical nurse]
Subtheme 3.2: Inadequate staff and training
Providers felt that inadequate training on adolescent sexual and reproductive health was an obstacle to providing quality sexual health services. Participants described how they were facing the challenge of providing HIV services due to lack of technical updates. One of the participants said:
“[…] Health extension workers like me should be trained on sexual and reproductive health services. […] I took it as part of my course when I was in college. I mean, 9 years ago. I also suggest that teachers and health development armies should be trained.” [Female, Age
20–35, Health Extension Worker]
Another participant supplemented the idea of the shortage of healthcare providers as:
“We [Hospital Youth Clinic] have many clients. I mean flow of client is very high. We intentionally placed the clinic [Youth Friendly Clinic] with other specialty outpatient clinic. What I mean is that our trained healthcare providers give other healthcare services. [Male, Age: 20–35, Public Health Officer]
Subtheme 3.3: Long waiting time and inconvenient working hours
This subtheme explored the experience of providers and their colleagues about what hinders adolescents from accessing the services. Inconvenient working time and long waiting time were frequently mentioned barriers to accessing the service by adolescents. One of the participants said:
“I guess waiting time is very high. We [Hospital youth friendly service provider] receive many clients from the town, rural and rural Kebeles of the Zone and other Zones.[…] We [providers] can’t address majority of adolescents coming to our center. We focus on adolescents who have special sexual and other health problems due to overburden. I usually see that they don’t want such clinic because it is overcrowded.” [Male, Age: 36–50, Public Health Officer]
Theme 4: Community Level Barriers
This theme incorporates the experience of providers alongside the community that prevents adolescents from accessing existing health services.
Subtheme 4.1: Community’s bad attitude and lack information
This subtheme explains providers’ point of view about community’s knowledge and attitude towards sexual health services that hindered adolescents from accessing the service. Almost all participants agree that community’s negative attitudes about sexual health issues in one way or another have been negatively impacted adolescents from using the service. One of the participants stated the perception and attitude of the community as follows.
“Adolescents who come to our [Youth Clinic] centers are considered rude, but those who enter the church are considered polite by a church person. Some church fathers perceived that anyone can be cured of any disease, such as HIV / AIDS. […] Therefore, they do not go to health care providers. Church fathers do not discuss sexual matters. ” [Male, Age
20–35, Psychology]
Another participant stated that if adolescents went to the "youth clinic", the community would level them as "bad" boys or girls.
“[…] Guess what could have been male adolescents faced if any of the family members get “condom” in his pocket. A similar problem would happen if female adolescent was found to have a sexual couple. Parents or community see children as if they were guilty if they are found to go to health facilities for sexual health issues.” [Female, Age: 36–50, Clinical Nurse]
One participant mentioned that communities had violated adolescents’ right of using sexual and reproductive health services as:
“[…] I see that many investors employ early adolescents (approximately below 15 years of age). I mean, they are too kid. The household owners did the same. Let it be. Why do employers prevent such adolescents from going to youth health centers? Employers need to know that all adolescents have the right to use and complain about their sexual and reproductive health services, regardless of economic, social, sexual, sexual, or other factors.” [Female, Age
36–50, Clinical Nurse]
Subtheme 4.2: Lack of parental and social support
This subtheme explores providers experience and perception about parents’ and communities’ support for adolescents when complain about using the services. Adolescence punishment, discrimination, and minority control for a variety of reasons were lack of parental and/or social support. Accordingly, eleven in twelve participants indicated that parents lacked discussion with their children about sexual and reproductive health matters. One of the participants clarified how parents and adolescents were not discussing about sexual health issues as:
“[…] Parents and teachers don’t talk about sexual and reproductive health issues. […] When I was in elementary school, she [participant’s mother] used to teach me about sexual health like contraception use and other issues. She used to tell me by relating with spiritual issues. […] She accepts when I wanted to go health facilities for help. I thank you, God. I didn’t face any problem. But, mine is not common to all parents. [Male, Age
20–35, Members of student counsel and RH and HIV/AIDS club]
Another participant stated that the lack of discussion of sexual health issues among religious people and adolescents prevented the use of sexual and reproductive health services.
“[…] Adolescents also practice sexual contact in religious settings especially in night program [“Amharic: ‘Adar’]. Majority of church fathers and followers don’t want to educate adolescents about sexual and reproductive health issues. Religious fathers have to work on more about sexual education for adolescents at early age. They have to promote the use sexual and reproductive health services when adolescent need to use such services.” [Female, Age: 20–35, Clinical Nurse]
Subtheme 4.3: Inadequate support to schools and youth centers
Under this subtheme, majority of interviewees pointed out how adolescents faced challenges of using existing services due to the fact that teachers, community and other stakeholders had not sufficiently supported schools and youth centers. One of the participants clarified as:
“Our [Youth counseling centers] link with health facilities had broken down. Almost all of youth centers which were promoting utilization of SRHs are clothed. Currently, only one out of ten centers in the town is functional. Members of the centers had left due to various reasons.[…] Medias ignored talking about HIV/AIDS and other SRH related problems. […] Reproductive health clubs in the school are not functional. […] Church fathers seem to let the community not to worry about HIV/AIDS.”[Male, Age
20–35, Sociology]
Subtheme 4.4: Inadequate literacy of sexual health
This subtheme focused on the perspectives of health care providers on the inadequacies of sexual literacy in relation to the use of sexual and reproductive health services. Half of the study participants believed that a lack of awareness about sexual health in schools was a barrier to accessing services.
One of the participants in the study believed that adolescents did not use sexual and reproductive health services because they did not learn about sexual health issues in formal education.
“I suggest that age appropriate sexual and reproductive health course should be given starting at primary school. […] I remember my biology teacher when I was a student. He [teacher] called different parts of our body, but silent when he reached at reproductive region. But, we know everything, even if they don't teach us. That would make students shy or fear go to health facilities for help” [Male, Age
20–35, Psychology]
One of the participants added the need of formal sexual health education at schools as:
“I suggest that curriculum should be designed. Adolescents should be educated starting from elementary school about sexual health. […] Let me ask you, why SRH services like condom are not available at high schools while it was available at Universities? Is it because teachers are afraid of encouraging sex between students? That is wrong because they know everything about sex.” [Female, Age
20–36, Language teacher]
Subtheme 4.5: Presence of unauthorized providers
This subtheme mainly focused on participants’ experience that unauthorized providers led adolescents not to use safe sexual and reproductive health services. Five of the twelve participants mentioned that adolescents used unapproved providers instead of accessing services from mandated health care facilities. One of the participants said:
“[…]They[adolescents] access from pharmacy. They don’t want to go to healthcare facilities for counseling. Currently, majority of adolescents want to use pills than using other methods like condoms. I remember when I was working with DKT Ethiopia. Previously, DKT was selling 10 Ethiopian Birr whereas pharmacies were selling 15 Ethiopian Birr. But, currently, DKT is selling 30 Ethiopian birr whereas pharmacies are selling 150 Ethiopian Birr.” [Male, Age
20–35, Psychology].
Another participant also said:
“Currently, adolescents are not using family planning. I think they might use family planning outside of this center. But, they come when problems related to pregnancy and sexually transmitted infections happen. As you know, they can access family planning everywhere (pharmacies). Adolescents come with complaints of menstrual irregularities. I guess, this is because they took emergency pills repeatedly. [Female, Age
36–50, Clinical Nurse]
Theme 5: Health System Level Barriers
This theme focused on participants' perceptions of a broader health care system that could negatively affect the use of services by adolescents. Two sub-subjects emerged: poor implementation and commitment; and low stakeholder engagement.
Subtheme 5.1: Poor implementation and commitment
Providers described many health system level challenges that have prevented adolescents from accessing sexual and reproductive health services. Providers pointed out that lack of funds; entrepreneurship and a lack of attention to the friendly-service were barriers to accessing the service in the study area.
One of the participants spoke of the problem of unemployment as:
“Ehh! I have noticed that unemployment is a challenge in terms of access to health care, including sexual health services. […] One day a girl asked me to carry my bag because she had no job. There is no job creation here. Do you think adolescents accept me when I talk about sexual health services while there are many competing needs?” [Female, Age
20–35, Urban Health Extension]
Many participants also indicated poor commitment of the government. One of the participants explained how government's lack of commitment as:
“[…] This was more effectively done when we were supported by non- government organization like pathfinders [NGO] and IFPH [NGO]. […] During that time, peers were calling for their friends who face difficulties in sexual health problems in the community and link to our center [Youth Clinic]. Peers also provide health information and promote where and when the youth friendly services were being provided. This was made through payment to selected peers for the work they did. But, when such programs phased out, activities of peer becomes down.[…] We [health facilities] couldn’t make it sustainable. [Male, Age
36–50, Public Health Officer]
Two of providers complained that implementation of the national strategy of youth friendly sexual and reproductive health strategy was not adequately responding the sexual health need of adolescents. One of the providers complained his doubt whether the strategy brought change to adolescents’ health seeking behavior as:
“Yea, we have strategy on youth friendly sexual and reproductive health services. But, I don’t think that it had brought intended results. How it was being implemented? What were the gaps? […] Is it really addressing sexual and reproductive health needs of adolescents? I think that this strategy has to be revised and include the current needs of adolescents.” [Male, Age: 36–50, Clinical Nurse]
Subtheme 5.2: Poor multi-sectorial engagement
This subtheme covers participants’ opinion on lack of cooperation among stakeholders to address the sexual health problems of adolescents. Four of the suppliers complained that there was a lack of cooperation between health professionals, health facilities, schools, youth centers, adolescents and youth-oriented sectors, and various governmental and non-governmental organizations. One of the participants described problem as:
“Okay, as you know community health activities increase demand in using any health care services including SRHs. Previously, we [Staffs of youth friendly association] were providing various sexual and reproductive health services through collaboration. We were supported by various NGOs. But, currently these activities are not sustainably being implemented. [..] Communities don’t own or support such centers [Youth Centers]. […] Government does not support the centers. Why governments consider youth centers as legal institutions?” [Male, Age
36–50, Psychology]
In addition, most of the studies that seem to have succeeded in overcoming barriers to accessing sexual and reproductive health services, nor did the research focus on adolescence, nor did the researchers' perceptions of providers.