Socio-demographic characteristics of participants
A total of 12 providers were participated in the study. The age of participants ranged from 22 to 49 years old with the mean age of 32.5 years old. A health professional from the city’s department of sexual and reproductive health; three health professionals who have worked in the unit of youth-friendly sexual and reproductive health services; a high school reproductive health club coordinator; two urban health extension workers; an urban health posts coordinator; two counselors who have worked in youth centers; and two adolescent representatives with experience in participating in reproductive health services in student clinics were participated in the study as a key informant interviewees. [Table 1]
Emergent themes and sub-themes
Barriers to using adolescent and youth-friendly sexual and reproductive services were addressed from the points of view of service providers. Five themes explaining barriers to using friendly-sexual and reproductive health services at various levels were identified in the data: provider, health facility, adolescents, community, and health system barriers. Themes were emerged as a result of coding and categorizing participants’ responses to questions addressing barriers that hinder adolescents from using the services. Some of the quotes are illustrated from the corresponding codes in each emergent theme and sub-themes [Table 2].
Theme 1: Provider level barriers
Based on this theme, healthcare providers gave personal and collegial experiences that restricted adolescents from accessing SRH services. Under this theme, three sub-themes were emerged: poor provider competency; confidentiality breaches, disrespect and discrimination of adolescents; and lack of provider follow-up.
Sub-theme 1.1: Poor provider competency
Under this sub-theme, participants discuss knowledge, attitude, communication, and technical skill gaps of healthcare providers that may prevent adolescents from using sexual and reproductive health services.
One of the participants working in a specialized youth center noted knowledge gap as:
“A male adolescent with a special need came to me. I was not familiar with that special need.[...] Instead of having sex with a female, he wanted to orgasm himself. He asked me what problems he would face if he continued to practice ’masturbation’. I was very much confused. I tried to advise what I perceived.[…] What I want to underscore here is that we [health care providers] should understand holistic sexual health practice of adolescents. If I fail 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 injectable contraceptives and went for sex. They [adolescents] don’t worry about of HIV /AIDS but, for pregnancy. Pharmacists inject contraceptives for adolescents of about 13 or 14 years old. Private clinics also do the same thing. […] I don’t know. Don’t healthcare providers know the risk?” [Male, Age: 20-35, Psychologist]
Urban health extension workers and other participants realized that they did not have enough knowledge to promote and educate about sexual and reproductive health issues for students in schools and adolescents in the community during outreach activities. One of the health extension workers reflected her knowledge and attitude towards sexual health education for adolescents as:
“[…] I invite other health professionals to provide health education there [school].[…] Parents should pray for their children.[…] 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 adolescents was influenced by a number of factors including cultural factors. The majority of the participants felt that adolescents did not talk openly to providers about sexual health problems for various reasons. This in turn prevented them from using SRH services. One of the participants said:
“I saw a 10-years-old boy. He came to our [center] condom outlet box. I was expecting as if he was going to a game center. But, he picked up a packet of condoms and kept in his pocket. I was shocked and asked him why he did that. He replied to me ’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 to be clear about sexual health in their mood. They would like the media to speak openly. We [health professionals] need to talk openly with adolescents. However, we often do not use a direct language. We 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 researchers’ observation also confirmed that other health workers either hadn’t knowledge or positive attitude towards youth-friendly services. During the interview, the investigators observed that other health care providers were disturbing both counselors and adolescents; moving in and out for their own purposes. Such phenomenon was common in almost all health facilities, with the exception of one specialized youth sexual and reproductive health center.
Sub-theme 1.2: Confidentiality breach, disrespect and discrimination of adolescents
This sub-theme discusses the experience of participants and their colleagues regarding breaching confidentiality as barriers to accessing sexual and reproductive health services. The sub-theme also explains disrespectful and discriminant behavior of healthcare providers.
One of the participants witnessed her own mistake 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 their own decision.” [Female, Age: 20-35, Health Extension Worker]
A counselor in the selected youth center also witnessed how healthcare providers disclose adolescents’ secrete as.
“Healthcare providers have a problem of keeping secrets about adolescents’ sexual issues. Let me give you an example that makes me angry. A girl from a school was attending phase-1 training on HIV / AIDS. She told a secret to the trainer [a male health care provider]. She told him that her families scheduled a female genital mutilation ceremony. Instead of counseling and linking her with the right service, 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, Psychologist ]
One participant reflected discrimination made by a healthcare provider based on sex of adolescent as:
“Approximately, 17 or 18 years-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 he wanted because a male provider was not around. So, she let him go to another private clinic. This teenager and many others may not want to revisit such healthcare services. […] Many healthcare providers believed that condom demonstration for male adolescents should be done by a male healthcare provider.[…]” [Female, Age: 20-35, Clinical Nurse]
One participant also shared his experience as sign of disrespecting adolescents
“I have often noticed that private health care providers work more for money than providing adolescent friendly services. I heard that they inject Depo [contraceptive] 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, Psychologist ]
Sub-theme 1.3: Providers' lack of follow- up
This sub-theme explains providers' lack of follow-up as a barrier to accessing sexual and reproductive health services. Majority of the health care providers reported that they had not followed up adolescents once they had provided services.
One of the participants described the follow- up problem as:
“[…] Both of them were students between 15 and 16 years old. They came for abortion service, but the service was not available in our center. I refer them to a private clinic. I guess they didn't have money. I referred to, but I didn’t know their fate. I didn't know where they went for such service.” [Female, Age: 20-35, Clinical Nurse]
A coordinator in a youth center also said that trained peers did not monitor other peers.
“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 continue to be trained. We have streamlined the process. Accordingly, peers perform their duty anywhere outside the center. But, we don’t have strong follow up system.” [Male, Age: 20-35, Psychologist]
One participant from the city's department of sexual and reproductive health services stated the follow- up gaps 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 (OWCY) though official letter to explain how it happened and how it could be prevented. 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 to explain the experience of healthcare providers and their colleagues regarding barriers that prevented adolescents from using friendly sexual and reproductive health services. Four sub-themes were emerged: fear to violation of confidentiality and cultural taboos, lack of information and poor attitude towards SRHs, preference to seeking care and peer influence, and financial problems.
Sub-theme 2.1: Fear to violation of confidentiality and cultural taboos
Under this sub-theme, major misunderstandings and legitimate breaches and fears due to cultural taboos are explored. Most of the participants reported that adolescents perceived violation of confidential information by the healthcare providers and adolescents are also afraid of being seen by other people when they visit youth friendly services.. One of the participants gave an example of how adolescents were prevented from accessing nearby sexual and reproductive health care services.
“[…] Overcrowding in the majority of our public health centers is not safe for adolescents. As a result, adolescents are afraid of losing their privacy and confidentiality. For example, I know some pregnant adolescents who went for abortions up to 32 kilometers to hide it.” [Male, Age:20-35, Public Health Officer]
Another participant added:
“[…] A pregnant adolescent and her sexual mate were not interested to be referred to government hospital for abortion. They felt fear and shame. They perceived as if they are not accepted by health care providers working in that government hospital. [Female, Age: 20-35, Clinical Nurse]
Sub-theme 2.2: Lack of information and attitude towards SRHs
This theme explores the experience of providers how adolescents’ poor knowledge and attitude towards SRHs prevented them from accessing the service. Accordingly, ten participants reported information gap of 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 exemplified adolescents’ misconceptions and poor practice regarding contraception.
“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 of them 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 negative attitude towards sexual health services. One of the participants 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 have wrong perception. They [adolescents] reflect 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. Female adolescents in schools act like commercial sex workers. I can say that paradigm of sex commercialization is seemed to shift from poor women to students [adolescent].” [Male, Age: 20-35, Psychologist]
Sub-theme 2.3: Preference to seeking care and peer influence
This sub-theme explores providers’ experience on how choice of care and influence of peers affect decision to use SRHs. Providers reported that adolescents seem to have concern on age and gender of healthcare providers to seek help from health providers. 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 adolescents’ preference as:
“[…] If they [adolescents] missed me [older health care providers]; they try to search for other two female professionals who were working here [Youth Friendly Service Clinic] 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 the participants had mentioned that adolescents were influenced by their peers in decision making of accessing SRHs. Majority of the healthcare providers reported that peers provide health information and promote where and when youth friendly services were being provided.
Sub-theme 2.4: Financial constraints
More than half of the participants believed that joblessness and limited access to household resources hindered many adolescents from accessing SRHs due to cost of service delivery, supplies, and transportation.
One of the interviewees described financial problems as:
“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:
“[…]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 to problem of household maids. You know, such maids may not have money to access any sexual health services.” [Male, Age: 20-35, Psychologist]
Theme 3: Health facility level barriers
This theme focuses on the experiences of participants and their colleagues concerning barriers for adolescents from using existing services. Three sub-themes were emerged: lack of supply and unsupported environment, long waiting and inconvenient working time, and inadequate staff and training.
Sub-theme 3.1: Lack of supply and unsupported environment
The sub-theme discusses providers’ experience regarding unavailability/limitation of resources needed to perform key activities to meet the sexual and reproductive health needs of adolescents. On the other hand, unsupported environment to responding to the needs of adolescents has been explored. The majority of participants strongly pointed out unavailability of supplies required to provide adequate and appropriate services for adolescents. Lack of written guidelines and lack of educational materials such as posters and flyers were also reported. One of the participants explained the problem as:
“I counsel how to use contraceptives. 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 services. We [health professionals] sometimes do not have some long-term contraceptive methods, HCG [pregnancy test] and STI medicines.” [Female, Age: 36-50, Clinical nurse]
Providers cited inadequate physical space and privacy as institution-level barriers to using adolescent sexual health services. The service providers also pointed out that youth clinics did not have enough entertainment and spaces. The researchers’ observation during the interview also proved that almost all YFS (youth-friendly service) clinics have only a single unit and is not separated from adult outpatient units. Some centers were also close to HIV/AIDS clinics.
Most participants agreed that the lack of privacy in health facilities and hospitals has resulted in fear of being seen by friends, relatives, or other community members. One of the participants described the situation as:
“[…]An auditor and a counselor share a similar room. An auditor gets out of 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]
Sub-theme 3.2: Inadequate staff and training
Providers felt that inadequate training on adolescent sexual and reproductive health was one of the barriers to providing quality sexual health services. In addition, inadequate trained manpower was also mentioned by majority of the participants as a barrier to providing quality services. Participants described how they were facing challenges of providing HIV services due to a 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 described a shortage of healthcare providers as:
“We [Hospital Youth Friendly Clinic] have many clients. I mean, flow of client is very high. We intentionally placed the clinic [Youth Friendly Clinic] with other specialty outpatient clinics. What I mean is that our trained healthcare providers give other healthcare services.” [Male, Age: 20-35, Public Health Officer]
Sub-theme 3.3: Long waiting and inconvenient working time
This sub-theme explores the experience of providers and their colleagues about what hinders adolescents from accessing services. Inconvenient working time and long waiting time were frequently mentioned barriers to accessing services by adolescents. One of the participants said:
“I guess waiting time is very high. We [Hospital youth friendly service providers] receive many clients from the town, and rural Kebeles of the Zone and other Zones.[…] We [healthcare providers] can’t address majority of the adolescents coming to our center. We focus on adolescents who have special sexual and other health problems due to overburden. I usually observe 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 explores the experience of providers alongside the community that prevents adolescents from accessing existing sexual and reproductive health services. Under this theme, five sub-themes were emerged: community’s bad attitude and lack of information; lack of parental and social support; inadequate support to schools and youth centers; inadequate literacy of sexual health; and presence of unauthorized providers.
Sub-theme 4.1: Community’s bad attitude and lack information
This sub-theme explains providers’ points of view about community’s knowledge and attitude towards sexual health services that hindered adolescents from accessing the service. Almost all participants agreed that community’s negative attitude towards sexual health issues in one way or another has negatively affected adolescents from using the service. One of the participants stated the perception and attitude of the community as:
“Adolescents who come to our [Youth Clinic] centers are considered rude, but those who enter the church are considered polite as perceived by church persons. 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, Psychologist]
Another participant stated that if adolescents went to youth clinics, the community would level them as "bad" boys or girls.
“[…] Guess what could have been male adolescents faced if any of the family members had got ‘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 were found to go to health facilities for sexual health issues.” [Female, Age: 36-50, Clinical Nurse]
One participant explained how communities had violated adolescents’ right to using sexual and reproductive health services.
“[…] 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 their economic, social, and sexual status.” [Female, Age: 36-50, Clinical Nurse]
Sub-theme 4.2: Lack of parental and social support
This sub-theme explores the experience of providers whether parents and other community members support for adolescents to use SRH services. Punishing, discriminating, and controlling decision making of adolescents for varieties of reasons were mentioned by the majority of participants that indicate the lack of parental and/or social support. In addition, eleven in twelve participants indicated that parents lacked discussion with their children about sexual and reproductive health matters. One of the participants clarified the idea as:
“[…] Parents and teachers don’t talk about sexual and reproductive health issues. […] When I was in elementary school, my 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 want to go health facilities for help. I thank God for having such mother. I didn’t face any problem. But, mine is not common to all parents. [Male, Age: 20-35, Student representative of RH and HIV/AIDS club]
Another participant stated that lack of discussion with religious people prohibited adolescents from using sexual and reproductive health services.
“[…] Adolescents also practice sexual contact in religious settings especially in night program [“Amharic: ‘Adar’]. Majority of the 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 use of sexual and reproductive health services when adolescent need to use such services.” [Female, Age: 20-35, Clinical Nurse]
Sub-theme 4.3: Inadequate support to schools and youth centers
Under this sub-theme, majority of interviewees pointed out many barriers that may prevent adolescents from using existing services because teachers, community and other stakeholders had not sufficiently been supported by the health facilities and the health system. One of the participants clarified the situation as:
“Our [Youth centers] link with health facilities had broken down. Almost all of youth centers which were promoting utilization of SRHs were closed. 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. […] Majority of 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, Social Worker]
Sub-theme 4.4: Inadequate literacy of sexual health
This sub-theme focuses on the perspectives of health care providers regarding inadequacy of sexual literacy as barriers to accessing ASRHs. Half of the participants believed that absence of formal sexual health education in schools could also be a barrier to accessing ASRHs for adolescents.
One of the participants explained how the absence of formal sexual health education affected adolescents regarding SRHs utilization.
“I suggest that age appropriate sexual and reproductive health course should be given starting in primary schools. […] I remember my biology teacher when I was a student. He [teacher] called different parts of our body, but silent when he reached at our reproductive region. But, we know everything, even if teachers don't tell us. That would make students shy or fear to go to health facilities for help” [Male, Age: 20-35, Psychologist]
One of the participants added the need of formal sexual health education in schools.
“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 was not available in high schools while it was available in Universities? Is it because of that teachers are afraid of encouraging sex between students? That is wrong because adolescents know everything about sex.”[Female, Age: 20-36, Coordinator of RH and HIV/AIDS club in a school]
Sub-theme 4.5: Presence of unauthorized providers
This sub-theme mainly focuses on participants’ experience whether the presence of unauthorized providers led adolescents not to use ASRHs. Five participants mentioned that adolescents used unapproved providers instead of accessing services from accredited health care facilities. One of the participants said:
“[…]They[adolescents] access contraceptives from private pharmacies. They don’t want to go to healthcare facilities for counseling. Currently, majority of adolescents want to use contraceptive 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, Psychologist].
Another participant also said:
“Currently, adolescents are not using contraceptives. I think they might use contraceptives outside of this center. But, they come when problems related to pregnancy and sexually transmitted infections happen. As you know, they can access contraceptives 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 explores experience of providers regarding a broader health care system that could negatively affect the use of services by adolescents. Two sub-themes were emerged: poor implementation and commitment, and low stakeholder engagement.
Sub-theme 5.1: Poor implementation and commitment
Providers described many health system level barriers that have prevented adolescents from accessing sexual and reproductive health services. Barriers to accessing ASRH services in the study area were lack of funding, job creation, and lack of attention to youth friendly-services as to participants.
One of the participants described unemployment as a barrier to accessing ASRHs 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, Health Extension Worker]
Majority of the participants also indicated poor commitment of the government. One of the participants explained how the government lacked commitment as:
“[…] AFSRHs 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 a 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 the strategy has to be revised and include the current needs of adolescents.” [Male, Age: 36-50, Clinical Nurse]
Sub-theme 5.2: Poor multi-sectorial engagement
The sub-theme discuses opinion of participants regarding the lack of cooperation among stakeholders in addressing sexual and reproductive health needs of adolescents. Four participants complained the lack of cooperation among health professionals, health facilities, schools, youth centers, adolescents and youth-oriented sectors, and various governmental and non-governmental organizations. One of the participants described the problem as:
“Okay, as you know community health activities increase demand in using any health care services including SRHs. Previously, we [Staffs of youth centers] 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, Psychologist]