UNIT 15:
DESIGNING ADOLESCENT SERVICES
INTRODUCTION:
To successfully serve adolescent clients with sexual and reproductive health care, service programs must attract, adequately and comfortably meet the needs of, and retain these clients. By conducting a facility assessment, participants learn to identify and evaluate the characteristics of youth-friendly services. The knowledge gained from the assessment can then be applied to services that are provided in their own clinics. To ensure that services are friendly and accessible to all adolescents, when conducting the assessment participants need to keep in mind the different vulnerability factors identified and discussed in the previous units. When it comes to youth with disabilities, the assessment will need to consider the accessibility of the services. The assessment will be conducted with the full participation of adolescents with different types of disabilities in order to identify the barriers that limit persons with disabilities to access information and services, to evaluate the characteristics of youth-friendly and disability-inclusive services, and to discuss any necessary adaptations and accommodations. The assessment phase can be expanded to include a participatory accessibility survey as part of a monitoring and evaluation plan to be jointly implemented by the stakeholders that take part in the project.
> TrainerÕs Note: This unit is designed to be delivered with youth trainers. The lesson and activities can be modified for an adult provider-only participant group, but trainers are strongly encouraged to include youth participants. The participation of youth trainers with different types of disabilities within the training is essential. Accommodations (sign language interpretation and/or Computer Aided Real-Time Transcription (CART) 1 personal assistants, braille, large print, easy-to-read materials, etc.) should be provided as needed to ensure the full participation of young trainers with disabilities. 
     	UNIT TRAINING OBJECTIVE:
To help providers evaluate and develop youth friendly services in their clinic or organization and take into account the needs of all youth clients, including adolescents with disabilities.
     	SPECIFIC LEARNING OBJECTIVES:
By the end of the unit, participants will be able to:
1. Define what makes services youth friendly. 
2. Discuss different models of service delivery for adolescent clients. 
3. Demonstrate how to evaluate and plan youth-friendly services that respond to the needs of all clients, including adolescents with disabilities.
     	TOTAL TIME: 8 HOURS 30 MINUTES
UNIT OVERVIEW: 
Session
Methods
Materials
Time
15.1
Trainer presentation
Small group activity
Slides 15.1-15.6
Flipcharts and markers
Participant Handouts 7a-c
1 hour 15 minutes
15.2
Trainer presentation
Individual worksheets 
Slides 15.7-15.14
Participant Handout 15a
Flipcharts and markers
1 hour 30 minutes
15.3
Group discussion
Site visit
Flipcharts and markers
Participant Handouts 15b-c
5 hours 15 minutes
Unit Summary
Pair interview
None
20 minutes

     	WORK FOR TRAINERS TO PREPARE IN ADVANCE:

* Make arrangements for a clinic visit well in advance and check the arrangements again during the course (several days before the visit is scheduled). Ensure the clinic visit is accessible to persons with disabilities to allow everybodyÕs participation. If necessary, contact in advance a local Organization of Persons with Disabilities for assistance. If possible, divide participants up into several groups and schedule visits at 2 or 3 clinics in the area. 
* Prepare copies of Participant Handouts 15a-e. Make sure you prepare extra copies of Participant Handout 15c so that participants can assess their own facility after the training.
* Review slides 15.1-15.14 and content from sessions. 
* Discuss and plan with youth co-facilitators how to divide presentation and activities. 

     	MAJOR REFERENCES AND TRAINING MATERIALS:
International Planned Parenthood Federation (IPPF). 2008. Provide: Strengthening youth friendly services. London: IPPF. 
Simon, C., R. Benevides, G. Hainsworth, G. Morgan, and K. Chau. 2015. Thinking outside the separate space: A decision-making tool for designing youth-friendly services. Washington, DC: Evidence to Action Project/Pathfinder International. 
UNFPA and Women Enabled International. 2018. Women and Young Persons with Disabilities. Guidelines for Providing Rights-Based and Gender-Responsive Services to Address Gender-Based Violence and Sexual and Reproductive Health and Rights for Women and Young Persons with Disabilities. New York: UNFPA
World Health Organization (WHO). 2009. Quality Assessment Guidebook: A guide to assessing health services for adolescent clients. Geneva: WHO. 







SPECIFIC OBJECTIVE 15.1: DEFINE WHAT MAKES SERVICES YOUTH-FRIENDLY
     	TIME
      1 hour 15 minutes
     	METHODS
* Trainer presentation
* Small group discussion
     	MATERIALS NEEDED
* Slides 15.1-15.6
* Flipcharts and markers
* Participant Handouts 8a-8c
* Participant Homework from Unit 8
     	STEPS

> TrainerÕs note: This program should be delivered by both the lead trainer and a youth counterpart, if available. The participation of youth trainers with different types of disabilities in the training is essential. Accommodations should be provided as needed to ensure full participation of young trainers with disabilities.  The trainers should work together beforehand to decide how best to divide the information, with a preference towards the youth trainer delivering more of the content. 

1. Introduce the session and the youth co-facilitator. Explain that one key pathway to success in designing youth-friendly SRH services is the active participation of young people in the design of services and monitoring of quality of care. Have the youth co-facilitator explain that young people with and without disabilities are best able to identify those barriers that prevent them from obtaining services, and strategies to overcome those barriers. 

Time: 15 minutes

2. Introduce the presentation Content: Characteristics of Youth-Friendly Services (Slides 15.1-15.6) below. 

       Content: Characteristics of Youth-Friendly Services (Slides 15.1-15.6)
	(Source:  Simon et al)
       Slide 15.1: 5 Characteristics of Youth-Friendly Services
WHO has established that youth-friendly services are:  
* Equitable: All adolescents, not just certain groups, are able to obtain the services they need including adolescents with disabilities, refugees, migrants, adolescents from poor and remote areas.
* Accessible: All adolescents, including adolescents with disabilities, are able to obtain the services that are provided. 
* Acceptable: Health services are provided in ways that meet the expectations of all adolescent clients. 
* Appropriate: The health services that adolescents need are provided. 
* Effective: The right health services are provided in the right way and make a positive contribution to the health of adolescents. 
Slide 15.2: Health Provider and Staff Competencies 
Health providers must be trained and equipped to reflect on how community social norms, local attitudes, beliefs and values influence the delivery of youth SRH and how their intersection with specific vulnerability factors (such as gender, disability, ethnicity, etc.) may result in additional barriers. 
To be able to offer disability-inclusive services, all staff need to be trained on how to best communicate with persons with different types of disabilities and provide them accommodations as needed. More information available in the ÒAdolescents with disabilitiesÓ chapter. 
All staff must be oriented on providing confidential, non-judgmental friendly health services to all adolescents. 
All staff must treat all young people with respect and demonstrate non-judgmental attitudes toward all regardless their gender, disability, age, ethnicity, etc.  
All health providers must be aware of and apply laws and policies related to youth SRH access and choice, including those that allow young clients to receive services without the consent of their parents or spouses. 
Slide 15.3: Universal Design
Services should follow the principles of Universal Design in order to ensure meaningful access to services to the widest number of clients, including adolescents with disabilities and vulnerable individuals. Universal design means the process of creating products (services, devices, environments, systems, and processes) which are usable by people with the widest possible range of abilities.  
The accessibility of facilities that where not developed following the principles of Universal Design can be improved through accommodations. Accommodations include different modifications and adjustments that ensure persons with disabilities can enter the facilities and use the services on an equal basis with others. These include but are not limited to: installing ramps, enlarging toilet stalls to accommodate wheelchairs and adding grab bars, providing sign language interpretation, braille, large print, and easy-to-read materials. Accommodations are not necessarily costly and can be done through the use of local materials and with the support of local Organizations of Persons with Disabilities. For additional information on accommodations related to communication in low-resource settings please see the chapter ÒAdolescents with disabilities.Ó    
Slide 15.5: Health Facility Characteristics
Hours are convenient for young people of all genders. 
Services are conveniently located so that young people of all genders can access them 
SRH services, including contraceptives, are offered for free or at an affordable price for young people. 
There are short waiting times for services. 
Counseling and treatment rooms guarantee both auditory and visual privacy. 
Where needed, specific times, days, or spaces may be set aside for young people, so that they can avoid being seen by the community. 
3. Pause and ask participants to reflect on these characteristics. Ask where and how these are different from the expectations for services for adult clients. Where are they the same? 

4. Record participantsÕ responses. Ask them if they can think of other needs of adolescent clients. Remind participants to keep in mind the needs of the most vulnerable youth groups, including adolescents with disabilities. 

Time: 1 hour
5. On another flipchart, divide the page in half. Label one side of the page ÒClinicÓ and one side ÒService.Ó 

6. Ask participants to think what changes could be made at their clinic or facility to make it more youth-friendly and disability-inclusive. Ask them to list out some changes that could be made at the clinic level, or in the running and environment of the clinic itself. Record their responses on the ÒclinicÓ side of the page. 

7. Now ask participants to brainstorm some ways they can make the service interaction (or the interaction between the provider and the adolescent client) more youth-friendly and disability-inclusive. Record their responses on the ÒserviceÓ side of the page. 

8. Divide participants into small groups of 3-4 people each. Ask participants to take out Handouts 8a-8c and their revised SRH History form that theyÕve developed. 

> TrainerÕs Note: Try to make sure that if there are multiple providers, clinics, or facilities, that they are divided into separate groups. For example, if there are four providers from the same clinic, they should be in four separate groups, and not one group of four. If you have multiple young people or youth co-facilitators, divide them among the groups as well to provide feedback. 

9. In their small groups, have participants review Participant Handouts 8a-8c and their revised SRH History forms. Have them compare the revisions theyÕve made to the history form, using the following prompts: 
a. If there was a pre-existing history form, how does yours change or update it?
b. What changes or updates did multiple people in your group make? Why? 
c. Did anyone have a change or a suggestion for their history form that was unique? What was it?
d. Were there any changes that your group didnÕt agree on? Why? 
e. What support would you need to make these changes at your clinic?

10. Allow 20 minutes for discussion in the small groups. Ask groups to appoint a rapporteur to report back at the end of discussion. 

11. Bring groups back and ask for the rapporteur from each group to report back to the plenary on what they discussed. Ask them to focus on what changes were most common and if there were any controversial changes. 

12. Ask the whole group to discuss the final question: What support would you need to make these changes at your clinic? Ask participants to think about how they would go about making changes, and what changes they would want to make. 

13. Use Slide 15.5: Design Characteristics below to close and summarize discussion. Compare the changes that participants said they would like to make with the characteristics of youth-friendly services contained in the slide presentation. 

Slides 15.5-15.6: Design Characteristics
* Information, education, and communication materials are available for young people and accessible to allÑincluding youth who face communication barriers, such as young persons with disabilities and young people with low literacy skills. According to the local resources available, adapted materials may include but are not limited to easy to read documents, images, videos with captions, Braille, and large print and audio materials.  
* Community health workers/peer educators are available onsite and/or in the community and provide or link young people to health services. 
* A diverse group of young people are involved in the design and monitoring of quality services, including adolescents with different types of disabilities.
* A discussion platform is organized in order to set up a list of shared indicators to monitor and evaluate the quality, youth friendliness, and accessibility of services.
* Written guidelines exist and are well-known and applied by all staff providing services to young people. 
* Drop-in clients are welcomed and/or appointments can be quickly arranged. 
* Youth-friendly services are publicized and promoted in the community. 


SPECIFIC OBJECTIVE 15.2: DISCUSS DIFFERENT MODELS OF SERVICE DELIVERY FOR ADOLESCENT CLIENTS 
     	TIME
       1 hour 30 minutes
     	METHODS
* Trainer presentation
* Individual worksheets
     	MATERIALS NEEDED
* Slides 15.7-15.14
* Participant Handout 15a: Choosing a YFS Delivery Model
* Flipcharts and markers
     	STEPS

> TrainerÕs note: This program should be delivered by both the lead trainer and a youth counterpart, if available. The participation of youth trainers with different types of disabilities in the training is essential. Accommodations should be provided as needed to ensure full participation of young trainers with disabilities. The trainers should work together beforehand to decide how best to divide the information, with a preference towards the youth trainer delivering more of the content. 

Time: 30 minutes

1. Remind participants of the discussion from Unit 9 about the multiple sources of information that young people use to learn about sexual and reproductive health. Ask participants if there are also multiple sources for where adolescents can obtain sexual and reproductive health supplies and commodities.

2. Tell participants that research shows that young people obtain information and services through many channels outside the clinic. The changing landscape for young people, including the changes in technology means that we need to start thinking about how to make youth-friendly services available where young people already gather, and not just wait for them to come to our clinics. 

3. Introduce the presentation Content: Different YFS Models (Slides 15.7-15.14 by saying that the presentation will explore some different models for delivering services, and how to know which model is best for the young people you are trying to reach. 

4.  Remind participants that while many of them may work out of clinics, there could be opportunities for them to suggest new clinical and outreach strategies to improve their service reach. 

> TrainerÕs Note: Pause frequently during slide presentation for questions, clarifications, or for participants to share their experiences with different models of service. If there is time, stop at each slide to ask which participants have experience with that model of service and what that experience is. If youth co-trainers are available, have them share their experience as well. 

       Content: Different YFS Models

       Source:  Simon et al

Slide 15.7: Model 1: Standalone Clinic
* A completely separate health center/clinic dedicated to serving adolescent and youth with a range of clinical services. 
* May also include peer educators or counselors for onsite counseling, as well as measures to promote services among young people in the immediate area. 
* Most common in cities or urban areas with a high volume of young clients to offset/justify costs. 
* High-volume clinics located in urban areas are the easiest setting where accessibility surveys can be implemented, Universal Design principles applied, and accommodations introduced, as the additional related costs can be better justified and/or rapidly recuperated due to high demand. 

Slide 15.8: Model 2: Separate Space for YFS
* SRH services for young people provided in a separate room or separate building by specifically trained providers, and/or
* Specific services for young people offered on specific days or times in a public or private facility. 
* Typically depends on a dedicated YFS provider who offers a wide range of integrated SRH services. 
* May include a separate YFS waiting area or Òyouth cornerÓ with information, education, and communications materials, peer educators or counselors, or separate triage and reception areas for young clients. 
* May also include subsidized pricing for young clients. 
* Most common in larger health centers or hospitals that have sufficient space.
* In these dedicated spaces, an accessibility survey to identify the barriers faced by youth with disabilities can be easily implemented, Universal Design principles applied, and accommodations introduced. 

Slide 15.9: Model 3: Mainstreamed YFS
* Services mainstreamed within existing services through a range of service delivery points in a public or private health facility. 
* Requires that all (or most) health providers and support staff in the health facility are trained to offer youth friendly services to young people as part of their routine service delivery. 
* Can be offered at any level of health facility, including primary care facilities. 
* May also include promotion strategies to attract young clients, coordination with peer educators and counselors, and tailored information, education, and communications materials for young people. 
* Mainstream YFS that are also disability-inclusive should be considered as the final goal to successfully reach all young people. 

Slides 15.10-15.11: Model 4: Mobile Outreach Services
* Services offered in strategic locations close to the people that most need them. 
* Can include:
o Mobile clinics (a full range of services offered in a specially equipped van/bus), 
o Satellite clinics (a full range of services offered in an existing non-health space on a routine basis), 
o Services offered by a mobile team of health providers at lower level health facilities that donÕt routinely offer those services, such as implants or IUD insertions, and
o Other non-routine outreach events. 
* Can be offered in non-health settings to reach targeted groups of young people, possibly including schools, workplaces, prisons, military facilities, sports clubs or events, shelters for street youth, and others. 
* Need to be promoted and tied to awareness-raising about types of services to be offered. 
* Inclusive mobile outreach services are very effective at covering the last mile between health facilities and clients, as they manage to serve all those clients who live far away from clinics and cannot benefit from accessible or affordable transportation to reach them independently. 

Slide 15.12: Model 5: Community-based Services
* Some youth-friendly services can be offered outside of static health facilities by peers or by community health outreach workers who have been trained and are supported to offer a range of SRH services. 
* Services may include counseling, select contraceptive methods (condoms, combined oral contraceptives, emergency contraception, injectables), HIV counseling and treatment adherence support, and referrals and vouchers for other services. 
* In this model, peers may be peer educators or Òpeer providersÓ and are adolescents or youth with similar characteristics as the target population. Community health outreach workers are lay health workers, usually adults, who are trained to provide a range of services at the community level. 

Slide 15.13: Model 6: Drug Shops and Pharmacies
* Young people increasingly seek sexual and reproductive health supplies and counseling directly from pharmacies and drug shops both in the private and public sector. 
* Can be easily accessible, fast, and relatively anonymous, but may also come with associated fees and costs. 
* Can be considered a model of delivering youth-friendly services if staff members are trained to provide accurate, non-judgmental, disability-inclusive and comprehensive counseling to adolescents and youth. 
* Frequently linked to social marketing campaigns that drive demand for particular commodities or brands. 

Slide 15.14: Model 7: SRH Services in Non-Health Settings
* Model varies from place to place to accommodate the conditions of the setting and the needs of the target population.
* Offered in a range of different non-health settings where there is a large adolescent and youth population. 
* The accessibility of the services needs to be ensured to allow the highest number of youth to benefit from the proposed services.

5. If you didnÕt have time to discuss during the slide presentation, pause now and ask which of the modelsÕ participants have the most experience with. Which models do they think show the most promise for reaching the adolescents in their community?

Time: 1 hour 
6. Distribute Participant Handout 15a: Choosing a YFS Delivery Model to participants. 

7. Divide participants into pairs and have them work together for 40 minutes to complete the handout. Divide young people into pairs with adult participants. 

8. Bring participants back to the group to discuss the handout. Ask if anyone had any challenges with the questions. Ask participants to share some resources they thought of for the landscape analysis and pre-existing resources. Flipchart the resources for participants. 

9. Close by reminding participants about the site visit for the next session. 






PARTICIPANT HANDOUT 15A: CHOOSING A YFS DELIVERY MODEL
Fill out alone or in pairs. 
Step 1: Health outcomes and target populations. 
The first steps in designing YFS is to ask: what are the desired health outcomes you aim to achieve? And which target populations of adolescents and youth are you trying to attract? Jot some notes below about the need in your area. 
Step 2: Consider the landscape. 
Consider whatÕs already available for young people in your community or catchment area. What health services exist? Who provides them? Are young people using the resources available to them, and if not, why not? Are young people with disabilities using them? If not, why? Note some of the organizations, people, or sources you could go to find this information for your area. Tip: Local young people and youth organizations are a good place to start to find out whatÕs available and what barriers exist. Local Organizations of Persons with Disabilities are a good place to start to find out more about the services available to youth with disabilities in the area.  
Step 3: Determine the package. 
The full range of SRH services can and should be provided for all adolescents and young people, but for efficiency, services should be prioritized based on need. The landscape analysis and consideration of the health outcomes and target populations will help determine which services should be provided and which model will work best. 
For each of the models below, fill out the services and target populations boxes from the list provided or add your own. Tip: there will be overlap and repetition among models, but not all services can be delivered by all models. 



Model
Service Package 
Target Population
List of SRH Services
Possible Target Populations
Standalone Clinic


* Counseling on SRH, including puberty, relationships, and sexuality. 
* HPV screening and vaccines
* Gynecological exams
* Pregnancy testing
* Contraception counseling and a full range of contraceptive methods
* Counseling and treatment of irregular or painful menstruation
* Reproductive and urinary tract infection testing and treatment. 
* STI counseling and treatment
* HIV counseling and testing 
* HIV treatment, care, and support
* Safe abortion and PAC
* Antenatal care, delivery services, and postnatal care
* PMTCT
* SGBV screening and care
* Age cohorts: 10-14, 15-19, 20-24
* Young men
* Unmarried adolescents
* Married adolescents
* Young parents
* LGBTI adolescents
* Young key populations (young MSM, IDUs, sex workers)
* Young people living with HIV
* In-school adolescents 
* Out-of-school adolescents
* Employed adolescents
* Out-of-work adolescents
* Adolescent heads of households 
* Orphans and vulnerable children
* Young refugees and migrants
* Urban adolescents
* Rural adolescents
* Young people living in poverty
* Young people with disabilities
Separate Space




Mainstreamed YFS




Mobile Outreach 




Community-based Services




Drug Shops and Pharmacies




Non-Health Settings






Step 4: Determine available resources. 
What are the available financial, in-kind, and existing resources available for service delivery, training, demand generation, or youth participation? Fill out the table below with some ideas. 

service delivery
training
demand generation
youth participation
financial resources






in-kind resources






existing programs/resources






Step 5: Decide on desired level of coverage. 
Are your services national? Local? Focused on specific geographic areas or target populations of adolescents and young people? Jot some notes below. 
Step 6: Select a model. 
Consider all of the above steps and review your notes. Consider whether more than one model is needed, and what the limitations of the model(s) might be. 
Which model/s could work for your area/population? 
___ Model 1: Standalone Clinic				___ Model 2: Separate Space
___ Model 3: Mainstreamed YFS				___ Model 4: Mobile Outreach
___ Model 5: Community-based Services	___ Model 6: Drug Shops and 
         Pharmacies
___ Model 7: Non-health Settings

Step 7: Make a plan. 
How can you introduce these ideas at your clinic? What could make these changes sustainable? Jot some notes below. 


SPECIFIC OBJECTIVE 15.3: DEMONSTRATE HOW TO EVALUATE AND PLAN YOUTH-FRIENDLY SERVICES
     	TIME 
       5 hours 15 minutes
     	METHODS
* Group discussion
* Site visit
     	MATERIALS NEEDED
* Flipcharts and markers
* Participant Handout 15b: Facility Assessment Tool
* Participant Handout 15c: Action Plan
     	STEPS

1. Gather participants together to discuss the purpose of the site visit. Remind participants that this is an exercise to see what improvements could be made, not a criticism of the existing services.  Any health service facility will always have room to grow. 

Time: 30 minutes
2. Review Content: Assessing Services below with participants. 

      Content: Assessing Services
* Conduct a needs assessment of adolescent services provided at the health facility.
* Identify existing problems in providing an integral quality service for adolescent clients. Tip: To enrich the discussion, identify specific youth populations such as youth with disabilities, unmarried girls, very young adolescents or others with unique needs.  
* Identify human resources and materials available in the institution.
* Develop proposals to solve the problems identified.
* Present an action plan to implement the proposals.
3. Pass out Participant Handout 15b: Facility Assessment Tool. Explain to participants that they will visit a nearby facility and conduct an assessment. The purpose of the assessment is to prepare participants to conduct their own facility assessment. The assessment should take about a half day. 

4. Walk through the steps of the facility assessment with the participants to make sure they are clear on the handout. 

5. Review Content: How to Conduct an Assessment below with participants. Make sure participants are clear on their role as observers only. They may ask questions but are not there to criticize or correct staff of the health facility. They should strive to respect clientsÕ privacy and interfere as little as possible with facility routine. 

      Content: How to Conduct an Assessment
* Talk with the staff at the facility, especially the clinic manager providing sexual and reproductive health services to assess willingness to strengthen adolescent services. The clinic in-charge will be key to leading all staff to change attitudes and practices toward improved adolescents. 
* Collect information, using the assessment tool, on the range and quality of adolescent services at the selected facility.
6. Divide participants into working groups and assign a youth co-facilitator or trainer to lead each group. 

Time: 3 hours
7. Split up and conduct facility assessment at nearby facility/facilities. Ask groups to return at a set time to finish their training. 

Time: 45 minutes
8. After participants return from their visit, ask each group to present the conclusions of their facility assessment to the larger group.  They should identify which areas they thought were good, which areas needed improvement, and recommendations for improving services. Allow 10 minutes for each group to gather their thoughts before presenting. 
9. Reconvene the larger group.  Allow each group 10-15 minutes for their presentation. The groups should compare their conclusions with those of the other groups. 
10. Distribute extra copies of Participant Handout 15b: Facility Assessment Tool so that participants can evaluate their own facility after the training.

Time: 1 hour
11.  Distribute Participant Handout 15c: Action Plan. Divide participants according to facility, clinic, or organization (participants who work at/come from the same facility or organization should work together). 

12. Ask participants to use their completed Handout 15a: Choosing a YFS Delivery Model and the facility evaluation they just completed to consider some initial plans for what they would like to improve at their own facilities. Allow 45 minutes for groups to develop their plans. 

13. Have groups spend 5 minutes reporting back to the plenary about their plans. Discuss commonalities and how they can support each other going forward. 


PARTICIPANT HANDOUT 15B: FACILITY ASSESSMENT FORM
Introduction
This guide is designed to help assessment teams, project managers, trainers, supervisors, and others collect detailed information on the range and quality of services provided to adolescents at a given facility or within a given program.  The guide is primarily a needs assessment instrument for determining the physical, informational, and training needs of facilities and programs preparing to improve services for adolescent reproductive health. This needs assessment also provides essential baseline information, allowing for repeated applications in order to examine changes and the impact of program interventions. Although the guide is primarily for use by a team, it may be used by an individual clinician. 
Determining minimum requirements for youth-friendly services is a difficult task. Given the great differences in contexts and availability of resources, there is no simple means for quantifying quality of care and services. This assessment guide can help to determine what each facility or program needs in order to improve the quality of services and design appropriate alterations or interventions.  

Using This Assessment Guide 
Discussing Objectives: Before starting to fill out the individual sections of this guide, it is extremely important that the assessment team discuss the objectives of the assessment with facility/program staff and supervisors. The assessment team leader should explain clearly how and why the assessment will be done, emphasizing that the assessment guide is designed not to find fault, but to identify areas where improvements can be made. 

Collecting and Recording the Data
Several methods will be used to collect the data needed to complete the assessment forms.  These include:
-Reviewing clinic records.
-Interviewing clinic managers and staff.
-Examining the clinic layout and environment.
-Interviewing clients.
-Observing provider-client interaction.
-Reviewing clinic policies and procedures.
You may need to use a combination of these methods to truly answer a specific question. Beside each question on the assessment form, there is a notation of the suggested methods to evaluate a particular aspect of youth-friendly services. 
Below are additional points to keep in mind while conducting the assessment.
* Consider whether a team or an individual will be most appropriate, and decide who will collect the data for different sections. 
* Before collecting data, review the descriptions of the characteristics of youth-friendly programs located at the end of the assessment tool. These descriptions should serve as a reference point for your assessment.
* Be as objective as possibleÑif a team is collecting data, it is important that you agree on definitions and standards before beginning the data collection.
* Take into account the routine of the service providers and try to make data collection as unobtrusive as possible.
* Whenever possible, obtain your information by observation.
* Consider timingÑwhich sections require clients, which sections can be completed when there are no clients.
* Be flexibleÑit may be impossible to complete the whole guide at one time. You may have to wait to observe some procedures.
* For each section, fill in the information requested.
* Use the comments/recommendations columnÑthese observations often provide the useful information.
* Use your judgment and ask other pertinent questions that may not be included in this assessment tool.

Completing the Guide: Complete only the sections of the guide that are relevant to the facility and the services it provides. The sections do not need to be completed in a particular order. For example, if there are adolescent clients at the facility, complete those sections that require observation of clients receiving services. You may need additional paper to record all your comments.
Using the Information: Go over the data with facility staff, looking at each section and interpreting the data as a whole. Discuss which areas show the greatest strengths and weaknesses and how care and facilities could be improved.  The assessment tool can provide baseline information for planning, prioritizing, and decision-making. However, the guide may be used in a number of other ways:
* As an ongoing monitoring tool
* For annual evaluations
* For designing training opportunities
* For developing workplans
* As a self-assessment tool for staff


Organization of Assessment Guide
This guide is organized according to the sections listed below. Each section starts with some introduction about why the information is being collected, why the topic is important, and how the observations/data collection should be carried out. 
I.	General Background Information
II.	Client Volume and Range of Services Provided
III. Personnel
IV.	Assessment of Youth-Friendliness


I. General Background Information
This section is designed to provide general information about the facility, its size and location, as well as details of the assessment process.  
Date of Visit: ______________________
Name of Facility: _______________________________________________________________________
Location: ___________________________________  Rural ______  Urban _______  Peri-urban_______
Type of Facility:	MOH ___________ 	NGO ____________	Other ____________________
Level of Facility:      ________________
Number of Rooms: 	Total ________   Waiting Room ______	   Examination Room ________   Lab ______  
Other _______   
Staff Interviewed:
       
	


	Person Conducting Assessment:

II. 

Client Volume and Range of Services Provided
This section is for gathering information on client volume and the range of services provided. In order to maintain and improve the quality of services, service providers should have experience in all aspects of adolescent care, including, where appropriate, counseling and the provision of contraceptive methods. 
Using the facility record books, record the following statistics for one month. Record the total number of clients served in the first column and the number of young people served, broken down by age, in the second column. If statistics vary greatly from month to month, collect 3 monthsÕ worth of information and record an average for a 1-month period. Any additional comments or recommended actions should be noted in the "Comments/Recommendations" column.
Service Provided
Total Clients Served
Total Young Clients Served
(20-24)       (15-19)      (10-14)
Comments/Recommendations

F
M
F
M
F
M
F
M

Counseling 
Contraception/Dual Protection









HIV/AIDS 









Nutrition 









Sexual Abuse









Other RH Issues
Testing
STI









VCT









Pregnancy









Treatment
STI (note if syndromic or etiologic)









Postabortion Care









Sexual Abuse or Violence









Other Services
Contraception









Abortion (if legal)









Prenatal Care 









Delivery 









Postnatal Care









Other services










Write in the hours (for example, 2-5 pm) for each day of the week that the following services are available to adolescent clients.



Schedule of Available Services
Services Offered
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Counseling 
Contraception/Dual Protection







HIV/AIDS 







Nutrition 







Sexual Abuse







Other RH Issues







Testing
STI







VCT







Pregnancy







Treatment
STI 







Postabortion Care







Sexual Abuse or Violence







Other Services
Contraception







Abortion (if legal)







Prenatal Care







Delivery 







Postnatal Care







Other services











III.	Personnel
This section is for gathering information about the staff providing services at the facility and their level of training. In order to provide services of good quality, facilities must have staff who can cover all aspects of adolescent care. 

List all personnel involved in the provision of adolescent services and the training they have received, using the codes beneath the table Common staff titles include manager, midwives, doctors, nurses, counselors, receptionist, and peer counselors; however some facilities or health systems may use different terms. Give whatever titles are used by the facility staff themselves. Also note what percentage of each provider's work time is devoted to serving adolescent clients.

Name
Sex
Title
Type of Training
Training Agency and Date
% of Time Serving Adolescents






















































1=Counseling			2=Peer Counseling		3=Family Planning 
4=Management of STIs		5=Postabortion Care	6=Adolescent Reproductive Health/Youth Friendly Services 7=Life Skills and Livelihood Training				8=Other


IV.	Assessment of Youth-Friendliness
Ask the questions below to the clinic manager or service provider and observe clinic operations where possible. Write brief answers in the ÒAnswerÓ column. Add additional findings or recommendations in the "Comments/Recommendations" column. Please refer to the ÒReview of Youth-Friendly Program Characteristics,Ó following this data collection form, for brief descriptions of specific youth-friendly characteristics. 
1. Location
Method
Answer
Comments/Recommendations
How far is the facility from public transportation?
E, IS, IC


How far is the facility from places where adolescents spend their free time?
E, IS, IC


How far is the facility from schools in the area?
E, IS, IC


2. Facility Hours
What time is the clinic scheduled to open?
IS, IC


What is the official closing time for the facility?
IS, IC


Does the facility have separate hours for adolescents? 
IS, IC


Is there a sign with services and clinic working hours?
E


What times are convenient for adolescents to seek services?
IS, IC


3. Facility Environment
Does the facility provide a comfortable setting for adolescent clients?
E, IC


Does the facility have a separate space to provide services for adolescent clients?
E, IC


Does the facility have a separate waiting room for adolescent clients?
E, IC


Is there a counseling area that provides both visual and auditory privacy?
E, IC


Is there an examination room that provides visual and auditory privacy?
E, IC



R = Review clinic records	E = Examine clinic layout and environment	IS = Interview clinic managers and staff
IC = Interview clients	O= Observe provider-client interaction	P = Review clinic policies and procedures
3. Facility Environment (continued)
Method
Answer
Comments/Recommendations
Are young men welcomed and served either for their own needs or as partners?
IS, IC, P


Are young women welcomed and served either for their own needs or as partners?
IS, IC, P


4. Staff Preparedness
Are staff trained to serve adolescent clients in RH?
IS


Are providers given specialized training?
IS


Did all staff members receive at least an orientation about adolescent clients? What type of orientation was this and how long was it?
IS


Do providers show respect for the client during counseling and consultations?
IS, IC


5. Services Provided
Is counseling on sexuality, safer sex, pregnancy prevention, and STI and HIV prevention provided?
IS, IC, P


What contraceptive methods are offered?
R, IS, IC, P


Are condoms provided to males and females?
IS, IC, O, P


Are supplies (condoms, other contraceptive methods, and drugs) sufficient to meet the need?
IS, IC


Is pregnancy testing offered?
R, IS, IC, P


Is STI testing available? What type is available?
R, IS, IC, P


Are there other RH services in demand by young people that you offer? Which ones?
IS, IC


Do you make referrals for important needs you cannot meet (e.g. sexual abuse)? Please give examples.
R, IS, IC, P


Is there an effective formal referral system in place?
IS, IC, P


6. Peer Education/Counseling Program
Method
Answer
Comments/Recommendations
Is a peer education/counseling program available? If so, please describe.
IS, IC, O


How many peer counselors are working with the facility?
IS


How many hours a week do they each spend at the facility?
IS


Is there a system for supervising and monitoring counselors? If so, what kind of system?
IS, P


7. Educational Activities
Are educational materials available on-site (A/V, computers, printed material)? Which ones?
IS, IC, E


Are there print materials available for clients to take? Describe materials and comment.
IS, IC, E


In what languages are IEC materials available?
IS, IC, E


Are group (or rap) discussions held? Please describe.
IS, IC, O


Are there ways clients can access information or counseling off-site (telephone hotline, website, materials sent by mail)? Please describe.
IS, IC, E


8. Youth Involvement
What ways can adolescents suggest/recommend changes to make services more comfortable and responsive?
IS, IC, E, P


Are adolescents involved in decision-making about how programs are delivered? How?  
IS, IC, P


How can adolescents be involved in decision-making at the facility?
IS, IC


What other roles can adolescents play in clinic operations or guidance?
IS, IC


9. Supportive Policies
Are adolescents mentioned in any of the facility guidelines? How?
IS, P


Do written procedures exist for protecting client confidentiality? Please describe.
IS, P



9. Supportive Policies (continued)
Method
Answer
Comments/Recommendations
Is the registration process private so that other waiting clients cannot overhear the conversation?
IS, IC, E, P


Are records stored so that confidentiality is assured?
IS, E, P


Are there any contraceptive methods that adolescents cannot receive? Which ones?
IS, IC, P


Are spousal or parental consent forms required? Which type and under what circumstances?
IS, IC, P


Is there a minimum age requirement to serve adolescents? If yes, why and for what service?
IS, IC, P


Are adolescent clients served without regard to their marital status?
IS, IC, P


Are pelvic exams routinely required? For what reasons?
IS, IC, P


Do policies or procedures exist that pose barriers to youth friendly services?
IS, IC, P


10. Administrative Procedures
Can adolescent clients be seen without an appointment?
IS, IC, P


If appointments are required, can they be expedited for adolescent clients?
IS, IC, P


How long would an adolescent client wait, on average, to see a provider?
IS, IC


What is the average time allowed for client/provider interaction?
IS, IC, O, P


11. Publicity/Recruitment 
Does publicity about the clinic identify services offered and stress confidentiality?
IS, IC, E


Are there staff or volunteers who do outreach activities? If so, what type?
IS, IC, O


12. Fees
Method
Answer
Comments/Recommendations
How much are adolescents charged for specific methods and services?
IS, IC, P


Are these fees affordable by adolescents in the catchment area?
IS, IC





REVIEW OF YOUTH-FRIENDLY PROGRAM CHARACTERISTICS

1. Location
Existing facilities cannot address this variable, but new operations can consider location as a factor when determining a service site. Young people sometimes express a desire to go out of their neighborhoods so they will not be seen by family and neighbors. At the same time, young people do not want to or cannot travel too far to reach service sites. The locations should be in a safe environment and, ideally, should be available by public transportation.  

2. Facility Hours
Having clinics open at times when young people can conveniently attend is fundamental to effective recruitment and service provision. Such times typically include late afternoons (after school or work), evenings, and weekends. While young people who need urgent care may be willing to leave school or work for such services, those who need prevention services but who may be unaware of their importance, are often reluctant and give excuses instead of taking the time off.

3. Facility Environment
The service environment may vary with the specific target audience to be served. In general, young people prefer a setting that is comfortable, has posters or dŽcor that relate to their tastes and interests, and does not present an overly sanitized environment. This might include service providersÕ wearing street clothes rather than ÒmedicalÓ whites, but the need for this varies from place to place.
Creating separate space and special hours for adolescents appears more important for certain clients, such as young teenagers, first-time clinic users, non-sexually active clients, and marginalized young people who are especially suspicious of mainstream health care. A separate service can also facilitate providersÕ efficiency in arranging specialized youth-friendly features. Before considering such a special adjustment, a strong needs assessment among a diverse group of probable clients should be conducted.
Privacy and confidentiality rank extremely high among young people. Privacy must be arranged for counseling sessions and examinations; young people must feel confident that their important and sensitive concerns are not overheard or retold to other persons. Adequate space is needed for privacy and to assure that counseling and examinations can take place out of sight and sound of other people. This requires separate rooms with doors, and policies that support minimal interruptions and intrusions.  
Although not possible in all societies, welcoming male partners can prove beneficial where feasible. For a young woman, the accompaniment of her boyfriend to the clinic can be an important element in the decision to seek services. This support should not be dampened by his feelings of discomfort. Furthermore, opportunities exist to foster shared responsibility for decision-making and contraception when young men are present, as well as to serve the RH needs of males. It may be necessary to develop clinic programs designed especially for young males that are sensitive to male values, motivations, feelings, and cultural influences while encouraging equitable male and female relationships.

4. Staff Preparedness
Having a specialized staff that is trained to work competently and sensitively with young people is often considered the single most important condition for establishing youth-friendly services. Acquired skills must include familiarity with adolescent physiology and development, as well as appropriate medical options according to age and maturity. At least as important are interpersonal skills so that young people can be at ease and can comfortably communicate their needs and concerns. This objective is sometimes accomplished when providers are closer in age to, and/or of the same sex as, the client. The ability to communicate fluently in languages that young people speak who attend a given clinic is also important. In addition to those providing counseling and medical services to adolescents, other staff members should be positive toward these clients and oriented to young peopleÕs special concerns. Particularly important are the attitude and performance of the receptionist, who is typically the first point of contact for the young person. Refresher courses must be made available to keep staff members informed and their skills current.
While respect for young peopleÑan essential provider characteristicÑcan be fostered within a training exercise, some providers bring to their job deeply entrenched biases against adolescent sexual activity or find it difficult to relate to adolescents in a respectful way. Given this reality, clinic managers should carefully consider such attitudes as they select trainees or those who will work withÑor supervise staff to work withÑyoung people.

5. Services Provided
The more health needs of young people that can be met within the facility or program, the greater assurance that adolescents will receive the care they need. Whenever it is necessary to send young people to another location for another service, there is an increased risk that they will not actually show up. While it is not always possible, attempts should be made to identify and provide the most needed RH services as Òone stop shopping.Ó These services should include sexual and RH counseling, contraceptive counseling and prevention (including emergency contraception), STD and HIV prevention, STD diagnosis and treatment, nutritional services, sexual abuse counseling, pregnancy testing, prenatal and postpartum care, abortion services (where legal), and postabortion care.
It is desirable, but almost never possible, to provide services that meet all the needs of adolescents, including some types of specialized health care and related social services. Thus, it becomes very important in addressing the adolescentÕs overall needs to be able to refer to responsible agencies. Effective working arrangements should be established to ensure that adolescents receive the services they are referred to and to assure that referral sites provide appropriate youth-friendly treatment.


6. Peer Education/Counseling Program
Evidence shows that many young people prefer talking with their peers about certain sensitive issues (although they also tend to believe that health care professionals know more about the technical issues). It is productive, therefore, to have peer educators or counselors available as alternatives or supplements to some aspects of the counseling activities.  
A critical element for quality peer education and counseling is effective supervision for the peers, though the amount depends on the types of activities they carry out and the extent of training they have had. In addition to overseeing their activities and needs as volunteers (or paid staff), supervisors need to provide reinforcements of efforts, perhaps including some sort of rewards or morale boosters. Care must be given to maintain attention to peersÕ professional needs during their tenure through refresher courses and mentoring and not just during the training phase.

7. Educational Activities
Some young people prefer to learn about sensitive issues on their own, using written or audiovisual materials, because their discomfort level can be too great to retain information during a face-to-face session. Such learning can occur while clients are waiting to be seen, as with educational videos or computer-based health education.  Some materials should be available to take home too, so that young people can refer to them later, particularly if the topics are complicated (such as symptoms of STDs).  
While not all young people are comfortable in a discussion format with their peers, this type of information exchange can be very productive if facilitated by a trained person. Peer counseling/education helps adolescents to realize that their fears are not unique. It can also provide the support needed to obtain care or seek solutions to problems. Peer counseling sessions can be scheduled, provided as needed, and/or held while young people are waiting to be seen.  
Given the challenge of attracting young people to fixed clinic sites, clinics can increase their reach by other means of contact with clients. For example, telephone hot lines can be operated by trained counselors from the clinic site thus eliminating the need to come to the clinic for information or counseling. Counselors (peer or adult) and outreach workers (including community-based distribution agents) can go into the community to deliver services. Clinics can set up smaller branches or satellite clinics closer to where young people congregate or link services to schools. In some settings, clinics can also take advantage of increased computer accessibility by providing information via websites or interactively through online Òchat rooms.Ó  

8. Youth Involvement
A fundamental principle in design of youth-friendly services is to ensure participation of young people in identifying their needs and preferences for meeting those needs. Some characteristics, such as privacy, confidentiality, and respectful treatment are nearly always top priorities. Other features, such as the separateness of the clinic from other services and the importance of peer counselors, may vary according to the overall culture or the specific norms of the target population. In addition to creating an environment more likely to meet their needs, involving adolescents in the design of the program and in continuous feedback will enhance the ÒownershipÓ of the program. This feeling of ownership will motivate young people to recruit their peers and to advise on needed adjustments. There are roles that young people can play in the clinic program such as assisting with administrative tasks, sitting on advisory boards, serving as peer counselors, and assisting with monitoring and evaluation.

9. Supportive Policies
Given that reproductive health projects for young adults are new, operational policies governing how providers should serve this group are evolving and not always clearly spelled out. This makes service decisions subjective, placing the responsibility on providers who may have varying views. Clear, detailed operational policies are likely to result in a more consistent and evenhanded provision of services. And to the extent that such protocols are actively supportive of young peopleÕs access, there is a greater potential for recruiting and maintaining a young clientele. These policies should include clear protocols for protecting client confidentiality, including privacy in the registration process and the secure storage of client records. 
When laws restrict available services by age, clinics face constraints beyond their control. However, staff should have clear legal guidelines, with operational policies detailing the full extent of services allowable under the law.
A policy that has been pioneered in some youth-friendly clinics is the possibility of delaying procedures feared by young people, especially the pelvic exam and blood tests. This fear can deter young women from going to clinics and obtaining contraception when they first need it. When it is deemed that such procedures can safely wait until a subsequent visit, such a policy might encourage early clinic visits and earlier adoption of a contraceptive method.

10. Administrative Procedures
Because adolescents are present-minded and rarely plan ahead, the possibility of receiving services without an appointment can increase adolescent access. If an adolescent is turned away and told to return at another time, or if the adolescent must wait several weeks to be seen after making an appointment, there is a significantly greater likelihood that the potential client will not show up. With young people, it helps to Òseize the opportunityÓ when they show an interest in getting RH care. 
An experimental program succeeded in serving young people by drastically cutting waiting times for appointments; they gave teens priority consideration for family planning appointments, guaranteeing an appointment within 48 hours. Having to wait a long time to be served in a clinic, particularly with an increased chance that someone will see them there, is also unappealing to the adolescent client. Young people may choose to not even endure the wait initially, but if they do, this situation can be a barrier to their return. This kind of experience is more than likely told to peersÑprospective clientsÑand gives the facility a bad reputation that dissuades future clients. 
Young people tend to need more time than adults to open up and reveal very personal concerns. They usually come to the clinic with considerable fear, often with a worry about being pregnant, and require strong reassurance and active encouragement to speak freely. Time is needed to bring myths (such as girls cannot get pregnant at first intercourse) to the surface, to discuss them, and to dispel them. When possible, clinicians and counselors should plan from the start to schedule more time with young clients than with adult clients. In addition to responding to client concerns, providers should be able to cover questions about body image and development, relationships, sex and condom negotiation, as well as to clearly explain contraceptive method options and their possible side effects and management; this discussion is crucial to the compliance and retention of the adolescent client.

11. Publicity/Recruitment
Not only must adolescents know that clinics and other service programs exist and where they are located, but they must also know what services are provided.  Importantly, they must be reassured that they are welcome and will be served respectfully.

Participant Handout 15c: Action Plan
Action Required
Person Responsible
Date Planned/Completed
Obstacles






UNIT 15 SUMMARY
     	TIME
       20 minutes
     	METHODS
* Pair interview
     	MATERIALS NEEDED
* None
     	STEPS

1. Divide participants into pairs. Have them interview each other about the unit using the following  questions: 

* Was there something new you learned today?

* Do you feel confident about your ability to implement your action plan?


1 CART is a method of making spoken word accessible to individuals with hearing disabilities, cognitive, or learning disabilities. CART transforms spoken word into a written transcript in real time, so users can read what the speaker is saying. The transcript is typically displayed on a projector screen or the individualÕs own computer monitor.    
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Module 16/Unit 10



Module 16/Participant Handouts

116
Pathfinder International		  					Adolescent Curriculum

125
Pathfinder International		YFS Curriculum

120
Pathfinder International		Adolescent Curriculum