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Dine RD, Uwamahoro V, Oladapo JO, Eshun G, Effiong FB, Kyei-Arthur F, Tambe AB. Assessment of the availability, accessibility, and quality of sexual and reproductive health services for young people in conflict affected zones of Cameroon: a mixed method study. BMC Health Serv Res 2023; 23:1159. [PMID: 37884966 PMCID: PMC10601185 DOI: 10.1186/s12913-023-10142-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION Despite ongoing programs to improve young people's Sexual and Reproductive Health Services (SRHS) in the conflict plagued North West and South West Regions of Cameroon, there is limited evidence-based information evaluating SRHS. This study, therefore, aims to investigate the availability, accessibility, and quality of SRHS provided to young people in the North West and South West Regions of Cameroon. METHOD This is a cross-sectional mixed-methods sequential explanatory study conducted among healthcare providers and young people between 10 and 24 years in 6 selected urban and rural areas in North West and South West regions. Data was collected between December 2021 and September 2022 using an adopted checklist. A descriptive analysis was conducted for quantitative data. An inductive analysis was conducted for the qualitative data to construct themes. The findings from the quantitative and qualitative responses were triangulated. RESULTS There were 114 participants, 28 healthcare providers and 86 young people. Most provider participants were nurses (n = 18, 64.3%), working in religious facilities (n = 14, 50.0%), with diplomas as state registered nurses (n = 9, 32.1%). Also, more than half of young people (51.2%) were less than 20 years old, while there were more male young people (51.2%) than female young people (48.8%). Most respondents agreed that SRHS services were available, though they think they are not designed for young people and have limited awareness campaigns about the services. Reasons such as limited use of written guidelines, affected quality of SRHS. Participants revealed shyness, resistance from religious groups and families, insecurities from political instability, and inadequate training, among others, as barriers to SRH accessibility. CONCLUSION The study shows that SRHS are available but are not specifically designed for young people. Inadequate publicity for these services, coupled with the political crises and the ongoing COVID-19 pandemic, has increased young people's inaccessibility to SRHS. Young people usually have to finance the cost of most of the SRHS. The quality of service delivery in the facilities is inadequate and must therefore be improved by developing safe, youth-friendly centers staffed with well-trained service providers.
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Affiliation(s)
| | | | | | - Gilbert Eshun
- Seventh-Day Adventist Hospital, Agona, Asamang, Ghana
| | | | - Frank Kyei-Arthur
- University of Environment and Sustainable Development, Somanya, Ghana
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Mcharo RD, Kisinda A, Njovu L, Mcharo M, Mbwilo F, Mihale G, Komba B, Andrew E, Mayaud P, Kroidl A, Ivanova O, Msuya SE. Prevalence of and risk factors associated with HIV, Herpes Simplex Virus-type 2, Chlamydia trachomatis and Neisseria gonorrhoeae infections among 18-24 year old students attending Higher Learning Institutions in Mbeya-Tanzania. PLoS One 2022; 17:e0266596. [PMID: 35617304 PMCID: PMC9135268 DOI: 10.1371/journal.pone.0266596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/24/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sexually transmitted infections (STIs) are common among young people in low- and middle-income countries and are associated with negative reproductive and pregnancy outcomes. Most of the studies have assessed HIV among adolescents and young adults, with limited information on occurrence of other STIs in this population. This study aimed to describe the prevalence of and risk factors associated with Herpes Simplex Virus-type 2 (HSV-2), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Syphilis and HIV infection among young adults attending Higher Learning Institutions (HLIs) in Mbeya, Tanzania. METHODS We conducted a cross-sectional study among students aged 18-24years attending HLIs in Mbeya-Tanzania, randomly selected using a computerized random number. Participants were tested for HSV-2, CT, NG, Syphilis and HIV infection. We used a self-administered questionnaire to collect information on sexual activity and risk factors to the tested STIs. RESULTS We enrolled 504 students from 5 HLIs, with mean age of 21.5 years (SD 1.7). 17% of the students had at least one STI; prevalence was higher among females than males (21.1% versus 14.1%). CT (11%) and HSV-2 (6.1%) were the most common STIs, while NG (1.1%) and HIV (0.7%) infection had the least occurrence. None of the participants was diagnosed with Syphilis. In univariate analysis, predictors for STIs were Sex, inconsistent condom use in the past 4weeks, report of oral sex, sexual orientation (bisexual/homosexual) and having a sexual partner with an age-difference of at least 5years (either older or younger); while in the multivariate analysis, Sex, inconsistent condom use in the past 4weeks and sexual orientation (bisexual/homosexual) remained significant. CONCLUSION STIs such as Chlamydia and HSV-2 which are commonly asymptomatic are of concern among young adults attending HLIs. The latter is an important group that needs attention and recognition that is pivotal in transmission of STIs considering their risk. Information, Education and Communication (IEC) campaigns targeting young adults, especially those at HLIs, need to focus on exposure-risk minimization. Funding institutions that have invested heavily on HIV prevention campaigns should consider giving similar recognition to other STIs for a streamlined outcome.
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Affiliation(s)
- Ruby Doryn Mcharo
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
| | - Abisai Kisinda
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Lilian Njovu
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Miri Mcharo
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Florida Mbwilo
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Getrude Mihale
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Beatrice Komba
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Ernest Andrew
- National Institute for Medical Research-Mbeya Medical Research Centre (NIMR-MMRC), Mbeya, Tanzania
| | - Philippe Mayaud
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Olena Ivanova
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Sia Emmanueli Msuya
- Department of Epidemiology & Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Community Health Department, KCMC Hospital, Moshi, Tanzania
- Department of Community Health, Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
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Chiu C, Hunter LA, McCoy SI, Mfaume R, Njau P, Liu JX. Sales and pricing decisions for HIV self-test kits among local drug shops in Tanzania: a prospective cohort study. BMC Health Serv Res 2021; 21:434. [PMID: 33957903 PMCID: PMC8101213 DOI: 10.1186/s12913-021-06432-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/22/2021] [Indexed: 11/14/2022] Open
Abstract
Background Public health initiatives must look for ways to cost-effectively scale critical interventions to achieve high coverage. Private sector distribution channels, can potentially distribute preventive healthcare products to hard-to-reach populations, decongest public healthcare systems, and increase the sustainability of programs by getting customers to share costs. However, little is known about how sellers set prices for new products. By introducing a new product, HIV self-test kits, to local drug shops, we observed whether shops experimented with pricing, charged different buyers different prices, and whether prices converged within the local market over our study period. Methods From August to December 2019, we provided free HIV self-test kits, a new product, to 26 drug shops in Shinyanga, Tanzania to sell to the local community. We measured sales volume, price, customer age and sex using shop records. Using a multiple linear regression model, we conducted F-tests to determine whether shop, age, sex, and time (week) respectively were associated with price. We measured willingness-to-pay to restock test kits at the end of the study. Results 514 test kits were sold over 18 weeks; 69% of buyers were male, 40% were aged 25–34 and 32% aged 35–44. Purchase prices ranged from 1000 to 6000 Tsh (median 3000 Tsh; ~$1.30 USD). Within shops, prices were 11.3% higher for 25–34 and 12.7% higher for 45+ year olds relative to 15–19-year olds (p = 0.029) and 13.5% lower for men (p = 0.023) on average. Although prices varied between shops, prices varied little within shops over time, and did not converge over the study period or cluster geospatially. Mean maximum willingness-to-pay to restock was 2000 Tsh per kit. Conclusions Shopkeepers charged buyers different prices depending on buyers’ age and sex. There was limited variation in prices within shops over time and low demand among shopkeepers to restock at the end of the study. Given the subsidized global wholesale price ($2 USD or ~ 4600 Tsh), further demand creation and/or cost-reduction is required before HIV self-test kits can become commercially viable in drug shops in this setting. Careful consideration is needed to align the motivations of retailers with public health priorities while meeting their private for-profit needs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06432-1.
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Affiliation(s)
- Calvin Chiu
- School of Public Health, University of California, 2121 Berkeley Way, Berkeley, 94704, CA, USA.
| | - Lauren A Hunter
- School of Public Health, University of California, 2121 Berkeley Way, Berkeley, 94704, CA, USA
| | - Sandra I McCoy
- School of Public Health, University of California, 2121 Berkeley Way, Berkeley, 94704, CA, USA
| | - Rashid Mfaume
- Shinyanga Regional Medical Office, Shinyanga, Tanzania
| | - Prosper Njau
- Health for a Prosperous Nation, Dar es Salaam, Tanzania.,National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - Jenny X Liu
- Institute for Health and Aging; Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
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Ormel H, Oele G, Kok M, Oruko H, Oluoch B, Smet E, Indalo D. Reducing unmet need for contraceptive services among youth in Homabay and Narok counties, Kenya: the role of community health volunteers - a qualitative study. BMC Health Serv Res 2021; 21:405. [PMID: 33933101 PMCID: PMC8088547 DOI: 10.1186/s12913-021-06363-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Access to contraceptive services is a cornerstone of human well-being. While Community Health Volunteers (CHVs) promote family planning in Kenya, the unmet need for contraceptives among youth remains high. CHVs seem to pay little specific attention to the contraceptive needs of the youth. Methods We conducted a qualitative study exploring the role of CHVs in increasing access and uptake of contraceptive services among youth aged 18–24 years in Narok and Homabay Counties, Kenya. We undertook 37 interviews and 15 focus group discussions involving CHVs, youth, community members, community leaders, youth leaders and health programme managers. Data were recorded, transcribed, translated, coded and thematically analysed, according to a framework that included community, CHV and health system-related factors. Results CHVs often operated in traditional contexts that challenge contraceptive use among unmarried female and male youth and young married couples. Yet many CHVs seemed to have overcome this potential ‘barrier’ as well as reigning misconceptions about contraceptives. While private and facility-based public contraceptive services were somehow available, CHVs were the preferred service provider for many youth due to ease of access and saving time and transport costs. This was influenced by varied perceptions among youth of CHVs’ knowledge, skills and attitudes regarding contraceptives and provider-client interaction, and specifically their commitment to maintain confidentiality. Conclusions CHVs have the potential to increase access to contraceptives for young people, reducing unmet need for contraceptives. Their knowledge, skills and attitudes need strengthening through training and supervision, while incentives to motivate them and broadening the range of contraceptives they are allowed to offer should be considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06363-x.
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Affiliation(s)
- Hermen Ormel
- KIT Royal Tropical Institute, P.O. Box 95001, 1090, HA, Amsterdam, The Netherlands.
| | - George Oele
- Amref Health Africa, P.O. Box 30125, 00100 , Wilson Airport, Nairobi, Kenya
| | - Maryse Kok
- KIT Royal Tropical Institute, P.O. Box 95001, 1090, HA, Amsterdam, The Netherlands
| | - Happiness Oruko
- Amref Health Africa, P.O. Box 30125, 00100 , Wilson Airport, Nairobi, Kenya
| | - Beatrice Oluoch
- Amref Health Africa, P.O. Box 30125, 00100 , Wilson Airport, Nairobi, Kenya
| | - Eefje Smet
- Amref Flying Doctors Netherlands, Schuttersveld 9, 2316, XG, Leiden, The Netherlands
| | - Dorcus Indalo
- Amref Health Africa, P.O. Box 30125, 00100 , Wilson Airport, Nairobi, Kenya
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HIV prevention at drug shops: awareness and attitudes among shop dispensers and young women about oral pre-exposure prophylaxis and the dapivirine ring in Shinyanga, Tanzania. AIDS Res Ther 2021; 18:21. [PMID: 33902623 PMCID: PMC8074434 DOI: 10.1186/s12981-021-00343-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND HIV risk remains high among adolescent girls and young women (AGYW, ages 15-24) in Tanzania. Many AGYW experience stigma and provider bias at health facilities, deterring their use of HIV prevention services. Privately-owned drug shops, ubiquitous in many communities, may be an effective and accessible channel to deliver HIV prevention products to AGYW, including oral pre-exposure prophylaxis (PrEP) and the dapivirine vaginal ring. METHODS In July-August 2019, we enrolled 26 drug shops in Shinyanga, Tanzania in an ongoing study to create "girl-friendly" drug shops where AGYW can access HIV self-testing and contraception. At baseline, all shop dispensers were given basic information about oral PrEP and the dapivirine ring and were asked about their interest in stocking each. During the next 3-5 months, we surveyed AGYW (n = 56) customers about their interest in oral PrEP and the ring. RESULTS Among dispensers, the median age was 42 years and 77% were female. Overall, 42% of dispensers had heard of a medication for HIV prevention. Almost all dispensers reported some interest in stocking oral PrEP (92%) and the dapivirine ring (96%). Most (85%) reported they would provide oral PrEP to AGYW who requested it. Among AGYW customers, the median age was 17 years; 29% of AGYW were married or had a steady partner and 18% had children. Only 20% of AGYW had heard of a medication to prevent HIV, yet 64% and 43% expressed some interest in using oral PrEP and the dapivirine ring, respectively, after receiving information about the products. PrEP interest was higher among AGYW who were partnered and had children. CONCLUSIONS Despite low prior awareness of PrEP among shop dispensers and AGYW, we found high levels of interest in oral PrEP and the dapivirine ring in both groups. Community-based drug shops represent a promising strategy to make HIV prevention more accessible to AGYW.
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Dennis ML, Radovich E, Wong KLM, Owolabi O, Cavallaro FL, Mbizvo MT, Binagwaho A, Waiswa P, Lynch CA, Benova L. Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda. Reprod Health 2017; 14:130. [PMID: 29041936 PMCID: PMC5645984 DOI: 10.1186/s12978-017-0393-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/06/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries. METHODS We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach. RESULTS Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda. CONCLUSIONS Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.
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Affiliation(s)
- Mardieh L. Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Kerry L. M. Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Onikepe Owolabi
- Guttmacher Institute, 125 Maiden Lane 7th Floor, New York, NY 10038 USA
| | - Francesca L. Cavallaro
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | | | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA
- Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH 03755 USA
- University of Global Health Equity, Kigali Heights, Plot, 772 Kigali, Rwanda
| | - Peter Waiswa
- Makerere University School of Public Health, New Mulago Hill Road, Kampala, Uganda
| | - Caroline A. Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Community-based provision of family planning in the developing world: recent developments. Curr Opin Obstet Gynecol 2016; 27:482-6. [PMID: 26390247 DOI: 10.1097/gco.0000000000000214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The study reviews important contributions to the peer-reviewed literature on the community-based provision of family planning in developing countries, from 2012 to the present. RECENT FINDINGS The major areas on which recent reports have focused include pilot studies, drug shops, and new contraceptive technology. The key studies focus largely on the provision of injectable contraception at the community level. SUMMARY Decades of previous research on community-based family planning has focused on the traditional community health worker. Yet, recent developments in this field have expanded many areas that have been studied previously. A major emphasis of recent research has dealt with broadening the community-based locations from which clients can obtain injectable contraception. Drug shops in developing countries are promising locations for family planning services. They are ubiquitous, frequently accessed, and generally sustainable businesses. Also, a new formulation of injectable contraception in an easy-to-use delivery device is garnering global attention for its potential benefits in community-level use. Additional research and programmatic interventions are needed to better understand the training, policy, regulatory, and logistical needs to ensure quality service delivery.
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Mchome Z, Richards E, Nnko S, Dusabe J, Mapella E, Obasi A. A 'mystery client' evaluation of adolescent sexual and reproductive health services in health facilities from two regions in Tanzania. PLoS One 2015; 10:e0120822. [PMID: 25803689 PMCID: PMC4372447 DOI: 10.1371/journal.pone.0120822] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/06/2015] [Indexed: 11/18/2022] Open
Abstract
Unwelcoming behaviours and judgemental attitudes have long been recognised as a barrier to young people's access to reproductive health services. Over the last decade youth friendly reproductive health services have been promoted and implemented world-wide. However, long term evidence of the impact of these programmes is lacking. We report the results of a large mystery client evaluation of adolescent sexual and reproductive health services in Tanzania, a country that has had a long established youth friendly policy. Forty-eight visits made to thirty-three health facilities were conducted by twelve young people (six in each region) trained to perform three different scripted scenarios (i.e., condom request, information on sexually transmitted infections and family planning). The study revealed barriers in relation to poor signage and reception for services. In addition health workers demonstrated paternalistic attitudes as well as lack of knowledge about adolescent sexual and reproductive health services. In some cases, health workers discouraged young people from using services such as condoms and family planning methods. Lack of confidentiality and privacy were also noted to be common challenges for the young people involved. Intervention strategies that focus on changing health workers' mind-set in relation to adolescent sexual and reproductive health are crucial for ensuring quality provision of sexual and reproductive health services to young people. The study identified the importance of reception or signs at the health units, as this can facilitate young people's efforts in seeking sexual and reproductive health services. Likewise, improvement of health workers knowledge of existing policy and practice on sexual and reproductive health services and youth friendly services is much needed.
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Affiliation(s)
- Zaina Mchome
- National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - Esther Richards
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Soori Nnko
- National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - John Dusabe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth Mapella
- Ministry of Health and Social Welfare, Dar Es Salaam, United Republic of Tanzania
| | - Angela Obasi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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