Sexual and reproductive health needs of young people: Matching needs with systems
Abstract
Access to services is a central concern surrounding the promotion of sexual and reproductive health and rights (SRHR) of young people. A more holistic (so-called “positive”) approach toward SRHR is needed, as is provision of services that tackle sexual and gender-based violence, sexual diversity, discrimination, relationship issues, and fears and concerns about sex and sexuality. Despite efforts to provide youth-friendly services, the uptake of services by young people is very low. What must be taken into account are young people's pathways to seeking services; and the specific barriers they face before getting to the services, while receiving services, and after leaving the service delivery sites. Attention to the perceptions and needs of young people is essential, along with development of policies, services, and programs that address those needs, particularly the youth-friendly approach to service delivery.
1 Introduction
The world is home to the largest generation of young people in history, with more than 1.75 billion people aged between 10 and 24 years [1]. The World Health Organization (WHO) defines young people as those aged 10–24 years, while adolescents are defined as those aged 10–19 years. This is a very diverse group of individuals whose life circumstances and opportunities and obstacles to improve their lives vary considerably from country to country.
In 1994, the International Conference on Population and Development (ICPD) drew attention to the special needs of adolescents regarding sexual and reproductive health [2]. Statistics show that 17 million young women aged 15–19 years give birth every year, half of all new HIV infections are among people aged 15–24 years, and over 6000 contract the HIV virus daily [1]. There are 2.6 million deaths annually among young people, the majority of which are preventable.
At the 64th World Health Assembly, held in Geneva in May 2011, the report by the Secretariat on Youth and Health Risks and the Resolution proposed by Tunisia (cosponsored by Finland and Hungary) received overwhelming support and were adopted. The Resolution calls on Member States to increase their efforts on the health of young people and consider this important population group in all policies within and beyond the health sector [3].
2 A rights approach to sexual and reproductive services for young people
Given that the principle of nondiscrimination is central to human rights, and that discrimination itself constitutes a violation of human rights, one important way of combating stigma and discrimination in relation to young people's sexual and reproductive health and rights (SRHR) is within a human rights framework. Promoting rights-based perspectives in relation to HIV/AIDS, sexual diversity, and access to information and services is a powerful strategy to emphasize the validity of young people's claims to the knowledge and resources they need.
2.1 Sexual rights and sexual health of young people
Sexuality is central to all phases of a person's life, and this includes young people. Comprehensive sexuality education and accessibility of gender-sensitive services should be central to youth-friendly services. It is important that young people are able to explore, experience, and express their sexuality in healthy, positive, pleasurable, and safe ways. This can only happen when the sexual rights of young people are respected.
The International Planned Parenthood Federation's (IPPF) Declaration of Sexual Rights supports a comprehensive vision of sexuality [4]. It provides a framework for the application of basic human rights to sexuality. It is an important reference tool for service provision to all and addresses stigma related to sexuality.
Young people's sexual rights are more complex than those of adults. There is a common misconception that young people should not be sexual beings, with the exception of certain groups, such as those who are married or above a certain age. The concept of the evolving capacity of young people stems from the UN Convention on the Rights of the Child. “Evolving capacity” means that each young person gradually develops the ability to take full responsibility for their own actions and decisions. At any given age, some will be more mature and experienced than others. Social inequities also influence young people's capacities. Thus, striking the right balance between protection and autonomy is a complex process that requires looking at the individual capacity of each young person, rather than focusing on age.
3 The value of youth participation in programs
-
Sexual and reproductive health services often have a strong focus on physical issues, but the young people involved felt that their concerns are often more related to social and mental aspects of sexual and reproductive health.
-
Young people perceived that the services were for those who were sexually active or adults only.
-
Social stigma is a significant barrier for young people to access sexual and reproductive health services, along with physical and material barriers such as distance to services and limitations of time, mobility, and costs.
-
Peer educators and community mobilization form an important and effective strategy to increase awareness, demand, access, and quality, and also to establish partnerships with community. Young people utilize services more often when outreach activities are available; the services and condoms are free; and educators and professionals are young, nonjudgmental, of the same gender, and have a positive attitude toward young people's sexuality.
The concept “youth friendly” is used by many organizations and health professionals; however, there is no real consensus on what it means in practice. Quality aspects of youth-friendly services concern respecting confidentiality, giving choices, and raising awareness of rights. Youth friendliness goes beyond service delivery settings to include community acceptance of young people's SRHR. In addition, demand-driven services contribute to quality by responding to the realities of young people's lives. It is important to create demand among the widest possible audience.
This paper describes the relevant key aspects of youth-friendly services as part of a young person's journey and pathways to accessing health services. The paper also discusses how to: (1) create demand and make linkages with the community; (2) make young people accessing services feel welcome; and (3) follow up a young person's visit to the services.
4 Access to youth-friendly services
WHO defines an adolescent-friendly health service as one that is accessible, acceptable, equitable, appropriate, and effective [6]. Young people's access to services is affected by many factors, including ethnicity, lack of insurance coverage, clinical hours, transportation, attitudes and behaviors of professionals, and, most importantly, lack of privacy and confidentiality. A recent systematic review of contraceptive service delivery in the UK showed that the most significant concerns for young people are anonymity and confidentiality [7]. Fear of unfriendly and critical staff was also raised. A final evaluation study among 6 IPPF Member Associations showed similar results [8]. Health systems and providers must adapt to the needs of young people, particularly their preventive health needs.
5 Characteristics of young people accessing services
Service providers need to understand what makes young people seek services, but more importantly, what prevents them from coming. Providers need an understanding of the diversity of young people, their level of knowledge, and their perception of need. They must also realize that young people may be sexually active or not, married or single, HIV positive, heterosexual, homosexual, bisexual, or transgender. Not all young people accessing health services are literate, confident, know exactly what to expect, or are capable of explaining what they need or want.
6 Before a young person reaches a service delivery point
Research has revealed many hurdles for young people who want or need to use services, including inconvenient hours, legal and policy hurdles, confidentiality concerns, fear of discrimination, disrespect, and high costs [7].
Young people seeking services may be disproportionately (compared with adults) subjected to discriminatory behavior from professionals. Studies in Kenya, Laos, and Zambia documented that one-half to two-thirds of professionals were unwilling to provide contraceptives to adolescents [9]. Young people may be particularly reluctant to seek services where extensive physical examination is performed if confidentiality and privacy are not assured.
Although it may seem obvious, it is important to remember that despite how friendly a service may be, or how friendly the staff are, services cannot be considered “youth friendly” if young people are not actually using them. On the other hand, an effectively promoted service should not lack the necessary aspects of quality and warmth.
6.1 What makes young people access a service?
6.1.1 An attractive space
It is important that a clinic is attractive and appealing for young people, including input and support from the community and decorations selected by those attending.
6.1.2 Price and accessible hours
In principle, services for young people should be free of charge; however, if this is not possible, a voucher scheme for essential sexual and reproductive health services can be adopted to facilitate access.
6.1.3 Trained staff
Health professionals should have additional qualities on top of appropriate training. Staff across the service delivery point should respond in a friendly and nonjudgmental manner.
6.1.4 Promoting services in the community
In general, professionals concentrate on the service that they are providing, and in some cases on the needs and profile of the population, while neglecting the promotional aspect. Promotion may be perceived as being an additional effort, expense, and/or a diversion of resources. However, health promotion is important because it serves as the primary strategy to bridge the gap between existing services and young people.
6.2 Should a youth-friendly service be separate or integrated into existing services?
Creating separate facilities for young people is not always necessary; rather, the existing healthcare system should be organized to better address their needs [10]. Once young people have indicated their confidence and trust in the system, they will use it to obtain relevant information and services. To achieve this goal, specific barriers must be removed, such as professionals’ bias and negative attitudes toward sexually active young people. The interpersonal competence of professionals requires reflection on personal beliefs and the influence of those beliefs on their interactions with young people [11].
A youth-friendly service can only be effective and sustainable in an environment that enables a systematic approach to the work. For example, it is beneficial if systems are in place for the collection, analysis, and use of data for effective monitoring of service delivery and to plan and improve programs. In addition, systems should be in place to ensure effective management and policies (e.g. a child protection policy) that are developed in partnership with young people. Systematic, supportive supervision of staff and capacity building also help create an enabling environment for youth-friendly services.
7 Once a young person reaches the service delivery point
When a young person reaches a service delivery point, the first interaction is paramount in putting them at ease and establishing rapport. Expressing genuine interest and being courteous and sensitive helps establish trust. The visitor may have spent days or weeks thinking about whether or not to seek services. Their decision to come should therefore be rewarded. First impressions are powerful and a bad experience may deter a young person from returning.
It is also important to recognize that some young people may prefer to see a professional of the same gender; where possible, this choice should be offered to all attending the services.
The service facilities available should comprise a private and soundproof space so that information gathering and history taking can be done confidentially. Careful and comprehensive interviewing and history taking are essential to address a young person's general health and well-being, and particularly any concerns about sexuality, psychosocial and economic factors, performance in school or employment, family functioning, and the characteristics of their communities. A vital part of history taking is to assess a young person's “connections” with their parents, school, teachers, and peers.
7.1 What information or services should be provided?
-
Services should contribute in the most effective way to the sexual and reproductive well-being of young people.
-
Services should have the potential to prevent morbidity and mortality caused by sexual and reproductive health problems and issues.
-
Sexual and reproductive health counseling
-
Condom distribution
-
Contraceptives, including emergency contraception
-
Pregnancy testing
-
Safe abortion care (within the national legal context)
-
Reproductive tract and sexually transmitted infection testing
-
Voluntary counseling and testing for HIV
-
Gynecology services
-
Maternal care (prenatal and postnatal)
-
Sexual and gender-based violence support.
Research has shown that fear of a pelvic exam and myths or misinformation about contraception are often the reasons preventing young people from seeking services or behind a reluctance to use contraception [7]. Therefore, not providing comprehensive information on SRHR during consultation is a missed opportunity to address these myths and misinformation. Professionals should not limit the information given to issues related to clinical assessment. A comprehensive approach to SRHR is one that integrates information on contraception, sexually transmitted infections including HIV, pleasure and safe sex, as well as sexual rights. Professionals must use terms and words that a young person understands.
7.2 Establishing understanding and modeling consent
It is a general legal and ethical principle that valid consent must be obtained from the client before starting treatment or physical investigation, or providing personal care. This principle of modeling consent reflects the right of clients to determine what happens to their own bodies, and is a fundamental part of good practice.
7.2.1 Address expressed needs
It is important that young people are provided with the facts and information they are seeking. This will enable them to make an informed decision based on a clear understanding of the matters, be it testing for sexually transmitted infections or contraceptive fitting, one-to-one counseling, or group discussions on sexuality.
Walking into a clinic for the first time is a huge step for a young person, and they may lack the confidence to manage the situation. The process is an important part of personal development and, approached correctly, can be a positive experience and immensely empowering.
Learning about a young person's needs helps to model consent by providing a series of simple decisions from the start of the consultation, such as the time of the appointment and the treatment available. Consent is closely linked to choice and control, and giving the young person choices establishes a feeling of being in control from the outset. Asking questions is a simple way of establishing understanding and informed consent.
Finally, it is vital to reinforce that all discussions are confidential. Providers must always obtain consent from the young person to break that confidentiality.
7.2.2 Sexual history taking and gathering information
Taking a sexual history and gathering information about a young person's needs forms part of any SRHR consultation. This is a two-way process between the professional and the young person, and should include information about the visitor's past, present, and future. It sets the scene and lets the young person know that the professional will listen to them, understands and respects them without judgment, and is not to be feared. The approach should be warm and informative. The young person should be reassured that whatever is said is confidential, and any limitations to this should be clearly identified. It is important to reassure that the young person is in control of the situation and can change their mind or stop the discussion at any time.
7.2.3 Full assessment
A full assessment is essential to understand the needs, desires, concerns, capacity, and potential future actions of each young person. No two young people are the same, or reflect the same history or needs; likewise, age and gender should not be seen as definitive indicators of maturity, needs, or behavior. When assessing a young person's needs, professionals should consider all of the factors that impact their sexual and reproductive health.
7.2.4 Summary of the visit
Sum up the visit before a young person leaves the consultation room. Professionals should review the information related to the services provided, and reach agreement on where any results or information should be sent, such as the address that feels safe to the young person, or the possibility of a text to a mobile phone. If follow-up is required, its need should be explained and any barriers to attending should be discussed. Provision of written materials on relevant SRHR services is crucial. All young people should have the opportunity to provide feedback before they leave the delivery point.
7.3 Confidentiality
Confidentiality and medical ethics are guided by professional ethical guidelines, and confidentiality is at the heart of the code of ethics for medicine. For example, the International Federation of Gynecology and Obstetrics (FIGO) recognizes that health professionals should “protect confidentiality in health care” [11].
Each facility should have a confidentiality policy that should be endorsed by all staff and advertised. If a clinic wants to attract young people, it is important that they know that services are confidential.
Professionals must recognize that while young people should be provided with confidential care at all times, they may also be happy to discuss their health issues with their parents or others, as long as they remain in control of their private information. However, the third party should never be informed or involved without the young person's consent. While it is important to encourage communication between young people and their families as much as possible, it is also important to ensure that there are systems in place for those who do not wish to share information.
7.3.1 When legal obligations require a health professional to share private information
There are circumstances in which the duty of a professional to maintain a young person's confidentiality might be challenged, some of which are directly linked to the legal status of young people as “minors.”
In some countries the law requires parental consent for minors to access specific sexual and reproductive health services, or the law might state that a professional should report a woman or girl to the police who may have had an illegal induced abortion or be in a same-sex relationship. It is therefore essential to inform the young person at the beginning of a consultation about any legal obligation to involve their parents or report to the authorities.
Although in these circumstances the breach of confidentiality might be lawful, it may not be in line with the medical ethics that should guide practice. In countries where the law allows room for interpretation, the respect of confidentiality in line with medical ethics should always prevail. In certain situations, however, a professional may believe that the health and safety of a young person is at risk or that they may cause harm to others; therefore, the professional may feel that it is necessary or they have a legal obligation to transmit information to third parties; for example, if it is suspected that the young person is being sexually abused.
8 After a young person has left the service delivery point
8.1 Follow-up
Health professionals should always obtain agreement from the young person on the best way to contact them if necessary (i.e. by mobile phone, email, or post) and how to leave messages for them to minimize the chances of exposure of private information to family members or friends.
Strategic partnerships in SRHR are crucial to enable appropriate follow-up and effective referrals and cross-referrals, with particular focus on standard procedures for facilities to accept the young people.
9 Conclusion and recommendations
When young people have access to health and education, they become a powerful force for economic development and positive change. Professionals in their role as clinicians should continuously reflect on their values, attitudes, and commitment to the SRHR of young people, and must be competent to provide the services. There is an urgent need for more efficient, high-quality, interdisciplinary collaborative care, and greater access to it. Health managers should be proactive in advocating for changes in policies and laws that restrict access to sexual and reproductive health services for young people. It is also crucial to evaluate and document the impact of SRHR interventions on young people's morbidity and mortality.
Conflict of interest
The authors have no conflicts of interest to declare.
