Quality of youth friendly services at public health facilities in Debre Birhan Town: A mixed study

doi:10.21203/rs.3.rs-5100046/v1

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Research Article

Quality of youth friendly services at public health facilities in Debre Birhan Town: A mixed study

https://doi.org/10.21203/rs.3.rs-5100046/v1

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Introduction: Adolescents and youths require access to high-quality, youth-friendly services to address challenges related to sexual health, relationships, and the potential for early parenthood. In response, both the World Health Organization and the Ethiopian government have developed and implemented various strategies. However, despite these efforts, the quality of youth-friendly services provided by health facilities in Ethiopia remains inadequate.

Objective: the aim of this study was to assess the quality of youth friendly services provided in public health facilities in Debre Berhan town, 2023

Methods: A facility-based cross-sectional study, incorporating both quantitative and qualitative methods, was conducted from May 1–30, 2023. The quality of youth-friendly services was assessed using the Donabedian framework, which evaluates structure, process, and output components. Data were collected through a systematic sampling technique, utilizing an interview-administered questionnaire and an observation checklist. A significant association was identified using an adjusted odds ratio, with a 95% confidence interval and a P-value of less than 0.05.

Results: In this study a total of 422 youth friendly service clients’ age between 10-24 years were participated. The quality of youth-friendly services was 70.7%, 41.3, and 50.5% for structural, process, and output quality dimensions, respectively. Age (15-19) (AOR=0.31,95% CI:0.17, 0.56), clients who waited less than 30 minute (AOR=4.58,95% CI:1.67,12.55), clients who waited 30 minute to one hour(AOR=3.65,95% CI: 1.88, 7.06), not comfortable with sex of service providers (AOR=0.37,95% CI: 0.18,0.76), and payment status free of charge (AOR=2.38, 95%CI:1.36, 4.18) had statistically significant association with client satisfaction.

Conclusion: The study shows that, the overall quality of youth friendly service at public health facilities of Debre Birhan town was 54.2%, which was below the standard of care.

Sexual & Reproductive Medicine

Youth-friendly service

Adolescent

Donabedian Model

Ethiopia

The World Health Organization (WHO) defines adolescents as individuals between the ages of 10 and 19, and youths as those aged 15 to 24. These years are a crucial in a young person's life, marked by rapid development, learning, and self-discovery. It's during this period that access to proper sexual and reproductive healthcare becomes vital, as young people face challenges related to sexual health, relationships, and the possibility of early parenthood (1, 2, 3).

Approximately 1.8 billion young people live around the world, with about 90% living in developing countries. To cater to the healthcare needs of this group, the WHO has devised strategies, one of which is to offer high-quality Youth-Friendly Services (YFS) (1, 2).

Adolescent and young people's health needs are frequently ignored or overlooked all around the world (4, 5). As a result, many young people engage in dangerous behaviors, such as drug and alcohol addiction and harmful sexual practices, which exposes them to infectious diseases like HIV and hepatitis (6, 7). Most of the health challenges faced by adolescents and youths today are directly linked to pregnancy and childbirth. Teenage pregnancies, in particular, carry a higher risk of unsafe abortions, maternal mortality, and health complications (8).

The WHO introduced a variety of strategies to improve the health of young people, including developing evidence-based recommendations to support age-appropriate health services for adolescents, tracking the development of adolescent health, and working with youth-led and youth-serving organizations to establish national-level structures and processes to institutionalize adolescent participation (9, 10). One of the WHO’s methods was to improve the quality of adolescent health services through Youth-Friendly Services (YFS) (11). However, evidence from both high- and low-income countries indicates that adolescent services are highly fragmented, poorly coordinated, and uneven in quality (12).

Globally, > 1.5 million adolescents and young people aged 10–24 years died in 2019, primarily from causes that could have been avoided or treated (14). Adolescent mortality rates in low- and middle-income African nations are approximately thirteen times higher than those in high-income nations and over seven times higher among youths (15). Poor-quality health systems result in more than 8 million deaths per year in LMICs, leading to economic welfare losses of $6 trillion (23). Moreover, high-quality healthcare is inequitably distributed in many developing countries (23, 24).

Ethiopia developed the first strategic plan for adolescent sexual and reproductive health (2007–2015) (27). In addition, the Federal Ministry of Health (FMOH) also produced a comprehensive national policy for adolescent and youth health in 2016 (2016–2020) intending to reduce adolescent and youth mortality by 50%. Subsequently, over 44.7% of health facilities have started implementing YFS programs in Ethiopia, with 53.5% of health facilities in the Amhara region using an age-driven approach (3). However, only accessing quality services is not enough; quality, as an integral element to optimizing the health of young people, should not be neglected. Low-quality YFHS will not effectively address young people’s sexual and reproductive health problems (20–22).

Despite the implementation of such initiatives, youth mortality rates in Ethiopia remain high, reaching as high as 11.61 deaths per 1000 population, according to the 2016 Ethiopia Demographic and Health Survey (EDHS) (16). Injuries caused by traffic accidents, drowning, self-harm, violence, and maternal conditions were cited as the leading cause of death among the LS age group (17, 18).

Research in different parts of Ethiopia shows important problems in Youth-Friendly Health Services (YHS). For example, in Northeast Ethiopia, only 58.8% of YFHS facilities met the basic structural requirements. Moreover, only 46.4% of the samples satisfied the process standards, while 47.2% met the output standards (9). Meanwhile, a research conducted in southern Ethiopia indicated that YFHS facilities achieved only 54.4% structural performance, 42% process performance, and 49.1% output quality. (10). A thorough review and meta-analysis of youth-friendly services found that overall quality in terms of structure, process, and output—was just 54.22%, 35.44%, and 57.01%, respectively. These percentages are much lower than the WHO benchmark of 75% for high-quality services (11).

Many factors lead to low quality YFHS in Ethiopian healthcare facilities. These challenges include cultural barriers, poor infrastructure, lack of provider training, and generally low awareness among young people about available services (12).

In summary, although there have been several studies assessing the quality of YFHS in Ethiopia, a specific research gap exists regarding what affects the quality of these services in Debre Berhan. This study used both quantitative and qualitative methods to evaluate the quality of YFHS offered in public health facilities located in Debre Berhan. This project creates valuable data for planners and decision makers who want to enhance YFHS quality in that region.

Study area, design, and period

A facility-based cross-sectional study using both quantitative and qualitative approaches was conducted from May 1–30, 2023, in Debre Birhan Town's public health facilities in the North Shoa Zone of Ethiopia's Amhara region. Debre Berhan is located 696 kilometers away from Bahir Dar and approximately 130 kilometers north of Ethiopia’s capital, Addis Ababa. As for the population forecast for 2022, the town's population stood at 146,918, with almost 21% (30,853) being youths. Before becoming a metropolitan city, Debre Berhan had nine kebeles; however, as of the recently established structure, it currently comprises five administratively separate sub-cities. The town contains 29 medical facilities, including three hospitals (public, university, and private), five health centers, 22 pharmacies, and 10 private clinics, according to data from the North Shoa Zone Health Administration. Currently, three health centers provide youth-friendly health services in separate YFS clinics.

Populations

All young people aged between 10 and 24 years who visited the selected public health facilities in the town for youth-friendly health services were considered as a source population for the quantitative study. However, managers and service providers working at Debre Birhan public health facilities were the source population for the qualitative study.

Inclusion criteria

All young people aged between 10 and 24 years who visited the selected public health facilities in the town for youth-friendly health services at the time of the survey were included. However, youth-friendly service clients with emergency conditions, critically ill children, and adolescents who were under 15 years old and came alone to the health facilities were excluded from the study.

Sample size determination

The sample size was calculated using a single population proportion formula, considering the following assumptions: a 47.2% (37) overall youth satisfaction level, a 95% confidence level (CI), a 5% degree of precision, and a 10% nonresponse rate. After computation, the final sample size for the quantitative study was 422.

For the qualitative part, an in-depth interview was conducted with three primary health care unit (PHCU) directors and three YFS providers, who were purposefully selected, and twelve client-provider interaction sessions (WHO recommends at least three observations per site) were conducted.

Sampling techniques and procedures

The study was conducted at three public health centers, providing youth-friendly services at the time, (04, Tebassie, and 08 health centers). The sample was allocated proportional to the average monthly patient (YFS users) flow recorded in each health centers (506 in kebele 04 health center, 273 in Tebassie health center, and 312 in kebele 08 health center). Finally, the total sample of participants were selected using a systematic sampling technique. from each health center, the allocated number of participants were selected using a systematic sampling technique. The sampling interval (K^th value) was calculated as 1091/422 = 3, 1091 and 422 representing the total number of patients who attended YFS in Debre Berhan town and the sample size, respectively.

For key informant interviews, three health center heads were selected purposefully to obtain rich information on the availability of resources and health facility management issues related to YFS. Besides, three YFS providers were included to obtain information on resources, client-provider interactions, and other YFS quality issues. In addition, twelve customer-provider interaction observations were performed by a senior nurse, recruited from outside the study area, using a checklist.

Data collection tools and procedures

Quantitative and qualitative data collection methods were used to gather data from health facilities, YFS providers, health center heads, and youth clients attending the facility for YFS uptake. Quantitative data were collected using a structured questionnaire. The questionnaire included items to assess participants socio-demographic information, YFS utilization experience, and client satisfaction.

Qualitative data were collected through a client exit interview, facility observation, and client-provider interaction score sheets. Generally, structure (input), process, and output quality were measured using 41, 21, and 16 items, respectively.

In this study, data collection tools were adapted from the WHO (42, 43) and national guidelines (44). The tools were initially developed in English and translated into the local (Amharic) language, and then back to the English language by a language expert to ensure consistency and accuracy.

The quantitative data was collected, through interviews, by three clinical nurses. The qualitative data collection process involved the primary healthcare unit director and service provider's interview, client-provider interaction, and facility observations, which were conducted by one senior nurse. All data collection processes were supervised by a health officer. Data collectors, including the supervisors, were deliberately selected and did not work at the health centers under study. In addition, the audio-recorded data from the key informant interviews were compared with transcribed written notes before translation into English for completeness and accuracy, and the transcribed notes were read to key informants to assess accuracy and completeness throughout the transcription process.

Operational definitions

Adolescent and Youth Friendly Services are services that are accessible, acceptable, and appropriate for adolescents. They are also provided in the right place, at the right price (free where necessary), and delivered in the right way to be acceptable to young people (11). In this paper, the terms "adolescent-friendly health services and youth-friendly health services" will be used interchangeably.

Quality care

Health care service that fulfills a set of certain standards and is assessed as a triad of structure, process, and output dimensions (42).

Structural or input quality

The professional and organizational resources associated with the provision of health care (availability of adequate service providers, facilities, information, essential drugs, equipment, and basic infrastructure) (42, 44).

Process quality

Things are done to and for the client, like client-provider interaction, including privacy, good communication, education, and use of job aids, guidelines, and examination and treatment procedures, according to WHO standards (42).

Outcome quality

a measure concerned with youth clients’ satisfaction levels with youth-friendly services provided at YFS Corners (39).

Good quality or good standard of care

If a health center scores 75% or more above the WHO quality standards by combining the three quality assessment items for structure, process, and output it is deemed to provide good quality care (35, 43).

Standard of care or service

A care or a service delivered in accordance with technical and practical guidelines or protocols set by WHO and the FMOH (42, 44).

Level of Satisfaction

is the "proportion of clients who were satisfied with the services, represented by a five-point Likert scale, scored on an ordinal scale ranging from very dissatisfied (1) to very satisfied (5). For the overall satisfaction level, those who were satisfied with greater or equal to the factor mean score of the items (i.e., 3.38 as a cutting point in this study) were categorized as "satisfied," and those who were satisfied with less than the factor mean score of the items were categorized as "dissatisfied.".

Percentage of good scores

for structural quality, a good score represents a score of 33, 26, and 28 out of 41 for 04, 07, and 08 health centers, respectively, and for process quality, a good score represents a score of 49, 40, and 42 out of 105 for 04, Tebassie, and 08 health centers, the percentage is computed from the total number of good scores * 100 and divided by the total number of items used.

Waiting time was measured by the self-report of young clients from their arrival at the health facility until they received the services. At the same time, the latrine was considered clean when there were no feces on or near the seats of the latrines and when flies did not disturb clients. Similarly, clean water was declared available when there was piped or well-protected water in the health center (37).

Data management and analysis

The quantitative data were cleaned and checked for consistency, coded, entered Epi-Data v.4.6 software, and exported to Stata v.16.0 software for analysis. Descriptive statistics were computed to summarize the participants' sociodemographic characteristics and quality of YFHS. Multicollinearity was tested using the variance inflation factor, and all items were less than cutoff point 10. Model fitness was checked using Hosmer and Lemeshow's goodness-of-fit. Bivariate and multivariate logistic regression analyses were used to assess any association between each independent variable and outcome variable. Independent variables with a p-value of less than 0.25 during the bivariable logistic regression were entered into the multiple logistic regression analysis. Adjusted odds ratios with 95% confidence intervals were calculated, and P-values 0.05 were considered statistically significant. Finally, the quantitative data were presented in text, tables, and charts.

Qualitative data were sorted, coded, and analyzed using the content analysis method in Microsoft Excel 2010, and the results are presented as narratives in three main parts based on the Donabedian quality of care model (the structure-process-output).

Ethical consideration.

The Institutional Review Board (IRB) of Debre Berhan University’s Asrat Woldeyes Health Science Campus provided a letter of ethical clearance. The Debre Berhan health office provided a formal letter of approval, which was received. Written informed consent was obtained from the participants. In addition, for respondents aged below 18 years, oral assent from them and consent from their parents/guardians were obtained before collecting the data. The witness further confirmed that consent information was clearly explained to individuals who could not read or write, that the subject appeared to understand the information, and that informed consent was voluntarily given after the fact. Both before and during the investigation, participants were free to choose whether or not to participate. The participant names were left out of the questionnaire out of respect for their privacy. The information collected was kept private and was only used in the study. This research was conducted in accordance with the Declaration of Helsinki.

Sociodemographic characteristics of the participants

With a response rate of 100%, 422 youth-friendly service clients aged 10–24 years participated in the survey. The mean age was 20.14 (SD ± 3 years). Three hundred forty-one (80.8%) of the YFS clients were unmarried, 267 (63.2%) of the clients were students, and 325 (77.0%) of the clients identified as orthodox Christians. Additionally, 184 (43.6%) respondents were college graduates or above, and all respondents attended formal schooling. In terms of income status, 300 people (71.1%) respondents did not have income (Table 1).

Table 1

Socio-demographic characteristics of the study participants, Debre Birhan public health facilities, Northeast Ethiopia, 2023
Variable	Category	Frequency (n)	Percentage (%)
Age in years	10–14	35	8.3
	15–19	118	28.0
	20–24	269	63.7
Sex	Male	200	47.4
Sex	Female	222	52.6
Educational status	Primary school	128	30.3
	Secondary and preparatory instruction	110	26.1
	College and above	184	43.6
Marital status	Unmarried	341	80.8
Marital status	Married	81	19.2
Occupational status	Student	267	63.2
	Merchant	37	8.8
	Gov’t employee	54	12.8
	Unemployed	64	15.2
Religion	Orthodox	325	77.0
	Muslim	48	11.4
	Protestant	31	7.3
	Catholic	18	4.3
Having their own income	No	300	71.1
Having their own income	Yes	122	28.9

Structural quality of youth friendly health service

Approximately 33, 25, and 32 healthcare providers were present in each of the three health centers (04, 07, and 08). All of the service providers are young women aged 24 to 35. The operating hours were from 2:30 to 11:30 local time, Monday through Friday. No healthcare center offers services 24 hours a day, 7 days a week. The findings of the key informant interviews revealed that “There is a challenge to providing YFS seven days a week and 24 h a day. The health facility provides YFHS at a separate service delivery corner only on government working days, five days per week. The reason is the issue of duty.” (A25 years of female YFS provider).

“Due to budget constraints, which are a major challenge now, we cannot assign duty to YFS providers on separate YFS delivery corners.” On weekend days and nights, the YFHS is not provided at a separate YFS provision corner.” (Head of the health center, aged 34).

Youth-friendly sexual and reproductive health services were provided by trained providers at all facilities. However, each YFS provision corner has a single qualified health worker assigned to it.

All facilities have separate YFS departments and adequate medicines and supplies, which enable them to provide YFS to their clients. All minimum service delivery packages for YFS recommended by the WHO were provided at all health centers. In spite of this, all facilities experienced shortages and stock-outs of some essential drugs and supplies like HIV test kits and contraceptives, in the last 12 months. The 04 health center has a separate waiting room for adolescents and youth clients. The 07 and 08 health centers have no separate youth waiting area. In the youth waiting room, there were adequate and comfortable seats, and only one health center had IEC materials specifically developed for young people. On the other hand, only 4 health centers have provided orientation on adolescent and youth-friendly services for supportive staff.

Regarding fundamental infrastructure, every facility had running water, power, a communication device, running toilets with handwashing stations, and a place to dispose of garbage. None of the healthcare facilities had any policies, standard operating procedures (sops), or protocols in place to guarantee privacy, informed consent, a safe and welcoming atmosphere, confidentiality, or free or reasonably priced services. Furthermore, none of the medical facilities had instruments for supporting supervision. Three health centers offered AYFHS, guidelines for family planning, HIV counseling and testing, and information on sexually transmitted infections.

On the other hand, no healthcare facility has guidelines for complete abortion care. Furthermore, the results of the key informant interviews showed that there were no established protocols for providing basic services.

"Our facility does not have all the required guidelines and protocols. The town administrative health office and the nos have not distributed all required protocols to our health facility. Hence, we did not have a guideline for comprehensive abortion care." (A 28-year-old male health center head).

To divide the examination space from the consultation area, the examination rooms of the two medical facilities had screens or drapes. There was only one YFS location with a signpost; it included information about the SRH services offered to youth, but it omitted information about working days and hours. There are no peer education or counseling programs available at any of the three medical facilities. Each of the three healthcare facilities has a one-way functional referral mechanism in place for clients.

In terms of youth involvement, none of the facilities included youth as part of their governance structure for health service delivery planning, monitoring and evaluation. The healthcare centers located at 04, 07, and 08 exhibited structural good quality scores of 80.5%, 63.4%, and 68.3%, respectively. The overall percentage of good scores for YFS structural quality for public health facilities in Debre Birhan was 70.7%.

Process quality of youth friendly health service

According to these data, the YFHS has an overall process quality score of 41.3%. Tebassie (07) health center had a lower process quality score (38.1%) than the 04 health center (46.7%). The results of the observation of client-provider interactions revealed that all clients received attentive listening from their providers; nonetheless, only 40% of customers guaranteed their secrecy, compared to 46.7% who guaranteed their visual privacy and 33.3% who secured their auditory privacy. In a similar vein, not a single AYFHS provider has made an effort to establish a positive rapport with its consumers. Furthermore, 73.3%, 60%, and 46.7% of the clients received clear information about their medical condition, treatment options, and follow-up measures.

Vital sign measurements and explanation of the results of the physical was examined in 80% and 60% of the patients, respectively. Likewise, the providers gave 66.7% of the client sufficient time to counsel or consult on the issue. Only 33.3% of the clients were asked about their psychosocial history and requested their permission before physical examination. In addition, 46.7% of the clients received information on disease prevention and good living practices. Furthermore, just 20% of YFS practitioners employed audio-visual resources to describe illnesses, anatomy, or other topics pertinent to the consultation. Remarkably, none of the YFS providers employed job aids and case management standards, nor did any of the health facilities notify their clients about the resources available to them (Table 2).

Table 2

List of process quality measurement items fulfilled by the Debre Birhan Public Health Facilities in Northeast Ethiopia, 2023
Process quality measurement items	04 HC (%)	07HC (%)	08-HC (%)	Average facility (%)
Made an attempt to ensure visual privacy (closed door).	60	40	40	46.7
In an attempt to ensure auditory privacy	60	20	20	33.3
Introduce yourself first to the adolescent	0	0	0	0
Did the service provider ensure the client confidentiality?	60	40	20	40
Ask the adolescent to accompany them to the consultation.	60	40	60	53.3
Did anyone else enter the room during the consultation?	40	20	40	33.3
Listen carefully to what the client had to say.	100	100	100	100
Did the service provider measure the patient’s vital signs?	80	60	80	80
Discuss how to prevent diseases and what to do to stay healthy.	60	40	40	46.7
Take any psychosocial history.	40	20	40	33.3
Use job aids and case management guides.	0	0	0	0
Inform the adolescent client about the services available.	0	0	0	0
Provide accurate and clear information on the medical condition.	80	60	80	73.3
Provide accurate and clear information on the mgt/treatment options. ?	60	80	40	60
Provide accurate and clear information about follow-up actions.	40	40	60	46.7
Ask the client about the treatment options.	20	40	20	26.7
Check the client’s understanding of the information provided.	80	40	60	60
Use audio-visual materials to explain anatomy, diseases,	0	20	40	20
Ask the patient’s permission before the examination or procedure	40	40	20	33.3
Provide sufficient time for consultation.	60	60	80	66.7
Explain the results of the physical examination to the client.	80	40	60	60
Percentage	46.7	38.1	40.0	41.3%

Outcome quality of youth friendly service (client satisfaction, service utilization, and experiences)

According to the findings, roughly 277 (65.6%) of the YFHS users had visited medical facilities in the previous year; of these, 149 (53.8%) and 128 (46.2%) had gone once and twice to four times, respectively. Concerning the source of information for visiting medical facilities, peers and health workers provided 39.3% and 39.6% of the information, respectively.

In terms of using youth-friendly services, 318 (75.1%), 108 (25.6%), 88 (20.9%), 59 (14%), and 9 (2.3%) of the clients used services such as medical illness services other than reproductive health problems, HIV testing and counseling, IEC materials, STI services, and violence-related services, respectively. Furthermore, 63 (28.4%) of the respondents use family planning services; 10 (4.5%) use safe abortion services; and 30 (13.5%) used maternal health-related services. 371 (87.9%) consumers obtained all the services they needed on the day of their visit. 51 (12.1%) of service users, meanwhile, did not obtain the services they had requested. Lack of medication or supplies was the top excuse for skipping the services for 41 (80.4%) people, followed by difficulty or embarrassment over asking for care. Six (11.7%) and 4 (7.8%) providers were pressed for time.

In terms of the time taken to reach the medical facilities, 229 (54.2%) take less than 30 minutes, 188 (44.6%) take between 30 and 1 hour, and 5 (1.2%) take longer than 60 minutes.

Regarding wait times, 10.9% of patients waited less than 30 minutes, 65.6% waited between thirty and sixty minutes, and 23.2% waited over an hour after arriving at the medical facilities.

A 32-year YFS provider stated the following:

Client flow is increased from time to time; therefore, we do not address all clients within the national standard client waiting time because in this service delivery point, only one health care provider is assigned; thus, it is a big challenge to deliver services as per national standards.

For most clients, the facilities were clean for 367 (87.0%) service users. Similarly, most clients (353; 83.6%) were comfortable with the sex of their YFHS providers. The findings of the key informant interviews support this result.

"Most clients are comfortable with the sex of health care providers; for instance, female clients with sexually transmitted infections prefer a female health care provider, and clients who come with family planning services share their interests freely without any embarrassment." (32-year-old female YFHS provider).

It was suggested to 363 (86.0%) and 321 (76.1%) clients that they should tell their friends about the YFS offered at the health facility and return to the YFS corner in the future.

The most popular justifications for encouraging service use were: service quality 164 (45.2%); free service 82 (22.6%); friendly service providers 101 (27.8%); quick wait times 16 (4.4%); and availability of same-sex service providers 152 (41.9%). In terms of the clients' payment status, 115 clients (27.3%) received services freely, while 307 clients (72.7%) paid for them.

A key informant interview supported this finding: "Health facilities must provide youth-friendly healthcare services without charge; however, due to financial restrictions, health facilities are unable to cover the service fee. They pay for expensive laboratory urine tests for clients who do not have a source of income, especially those who use family planning services." (27-year-old YFHS provider)

"Since the compensation mechanism for exempt services is inconvenient, health facilities charge clients for pregnancy tests. Thus, contraceptive users face difficulties when paying for a pregnancy test to roll out pregnancy." (25-year-old YFHS provider)

Level of client satisfaction with YFS

Based on the Likert scale, the mean score was 3.38, and taking the mean score of client satisfaction as a cutoff point, approximately 213 (50.5%) with a 95% CI (45%, 55%) of clients were satisfied with the adolescent and youth sexual and reproductive health services provided at YFS Corner.

The satisfaction level varied across facilities, with the 04 health center having 109 (56.2%), the 07 health center 46 (43.4%), and the 08 health center 58 (47.5%). Regarding the sex of the client, 88 (44%) males and 125 (56.3%) females were satisfied with the service they received. The satisfaction levels among the 10–24, 15–19, and 20–24 age groups were 45.7%, 28.8%, and 60.6%, respectively. Regarding marital status, 47.2% were single, 64.2% were married, and satisfied with YFHS units’ services. Nearly half of 49.1% and 47.6% of employed and unemployed clients were satisfied, respectively. 51.9% of the student participants were satisfied with the services they received.

Related to educational status, the satisfaction level of clients attending primary school, secondary school, and college and above was 51.6%, 50.0%, and 50.6% satisfied with the services they received, respectively. Approximately 58.2% of clients who had their own income source were satisfied with YFHS services.

Regarding variables related to the characteristics of the services, most of the clients were satisfied with the understanding of information given by the health care provider (77.8%), cleanliness of areas surrounding the health facility (75.1%), waiting area comfort (69.7% and convenience of the location of the YFHS delivery point (62.8%), respectively. While 58.5% were satisfied with privacy protection during the consultation, 58.3% were satisfied with the treatment in a respectful manner, 57.6% were satisfied with the treatment procedure, 42.2% were satisfied with the length of waiting time, and 39.8% were satisfied with the cost of the services that the patient paid (Table 3).

Table 3

Characteristics of service and satisfaction among respondents who received health services from Debre Birhan public health facilities in Amhara region, Ethiopia, 2023 (n = 422)
Characteristics of the service	Satisfied N (%)	Dissatisfied N (%)
Convenience of the service opening hours	201(47.6)	221(52.4)
Length of waiting time	178(42.2)	244(57.8)
Friendliness with supportive staff	205(48.6)	217(51.4)
Friendliness with health workers	251(59.5)	171(40.5)
Waiting area comfort	294(69.7)	128(30.3)
Privacy protection during the consultation	247(58.5)	175(41.5)
Length of consultation time	197(46.7)	225(53.3)
Freedom to ask for healthcare providers	237(56.2)	185(43.8)
Cost of services you paid	168(39.8)	254(59.2)
Understanding the information provided by the service provider	328(77.7)	94 (22.3)
Treatment procedure	243(57.6)	179(42.4)
Adequacy of psychosocial assessment	210(49.8)	212(50.2)
Information on risk reduction and prevention is provided.	178(42.2)	244(57.8)
Convenience of locating the YFHS service delivery point	265 (62.8)	157 (37.2)
Treat the situation in a respectful manner.	246 (58.3)	176 (41.7)
Cleanliness of areas surrounding a health facility	317(75.1)	105(24.9)
Overall satisfaction	213(50.5)	209(49.5)

Overall quality of youth-friendly services

The UNFPA approach was used as a benchmark to categorize both the health facility and quality dimensions as good quality or good standard of care (≥ 75%) and poor quality or low quality or below the standard of care (< 75%). This study shows that the overall quality of youth-friendly services was 70.7%, 41.3%, and 50.5% for structural, process, and outcome quality, respectively. The process quality was the lowest and most compromised dimension compared to the other quality dimensions. By taking the average of the three quality dimensions, the overall quality of YFS at public health facilities in Debre Birhan was 54.2%, which was below the cutoff point (75%). Therefore, the quality of youth-friendly service at the public health facilities in Debre Birhan was poor or below the standard of care (Fig. 1).

Figure 1: Quality of youth-friendly health services in Debre Birhan town public health facilities, Amhara region, Ethiopia, 2023 (n = 422)

Client satisfaction with youth friendly health service

To limit the number of variables and unstable estimates in the subsequent model, variables with a p-value < 0.25 in bivariate logistic regression analysis were included in the multivariate logistic regression model. Factors found to be significant in the bivariate logistic regression analysis were age, sex, marital status, clients who had their own income sources, ever visiting YFS in the last 12 months, clients who utilized STI service, waiting time to get service providers, cleanliness of the health facility, comfort with the sex of service providers, and payment status.

On the other hand, variables significantly associated in the binary logistic regression but insignificant in the multivariable logistic regression were sex, marital status clients who had their own income sources, previous visit to YFS in the last 12 months, STI service, and cleanliness of health facility.

In this study, five variables were identified as statistically significant with adolescent and youth-friendly health services’ satisfaction. Accordingly, clients within the age group of 15–19 were 69% less likely to be satisfied with YFS than those within the age group of 20–24 years (AOR = 0.31; 95% CI: 0.17–0.56). Clients who waited less than 30 min were 4.58 times more likely to be satisfied with YFS than those who waited more than 1 hour (AOR = 4.58, 95% CI: 1.67–12.55). Similarly, clients who waited from 30 min to one hour were 3.65 times more likely to be satisfied than clients who waited more than one hour (AOR = 3.65, 95%CI: 1.88–7.06). In addition, clients who were not comfortable with the sex of service providers were 63% less likely to be satisfied with YFS than clients who were comfortable with the sex of service providers (AOR = 0.37, 95%CI: 0.18–0.76).

Moreover, clients who were free of charge were 2.38 times more likely to be satisfied than those who paid for YFHS services (AOR = 2.38, 95% CI: 1.36–4.18) (Table 4).

Table 4

Bivariate and multivariate logistic regression analysis of factors associated with YFS client satisfaction at Debre Birhan public health facilities in Amhara region, Ethiopia, 2023
Variables		Satisfaction (n)		COR (95%CI)	AOR (95%CI)
Variables		Satisfied (n)	Dissatisfied (n)	COR (95%CI)	AOR (95%CI)
Age	10–14 years	16	19	0.55(0.27–1.11) *	0.63(0.28–1.42)
	15–19 years	34	84	0.26 (0.16–0.42) *	0.31(0.17–0.56) **
	20–24 years	163	106	1	1
Sex	Male	88	112	0.61(0.41–0.90) *	0.97(0.58–1.62)
Sex	Female	125	97	1	1
Marital status	Unmarried	161	180	0.50(0.30–0.82) *	1.04(0.51–2.13)
Marital status	Married	52	29	1
Owning income	Yes	71	51	1.55(1.01–2.37) *	0.61(0.30–1.22)
Owning income	No	142	158	1	1
Ever visit YFS?	Yes	`144	126	1	1
Ever visit YFS?	No	69	83	0.72(0.49–1.08) *	0.92(0.58–1.45)
STI service	Yes	25	34	0.68(0.39–1.19) *	0.72 (0.37–1.42)
STI service	No	188	175	1	1
Waiting time (minutes)	< 30minute	31	15	4.75(2.24–10.07)*	4.58(1.67–12.55) **
	30–60 minute	152	125	2.8(1.71–4.56) *	3.65(1.88–7.06) **
	> 60minute	30	69	1
Cleanness of HF	Yes	194	173	1	1
Cleanness of HF	No	19	36	0.47(0.26–0.85) *	0.76(0.37–1.57)
Comfortable with sex	Yes	185	168	1	1
Comfortable with sex	No	28	41	0.62(0.37–1.05) *	0.37(0.18–0.76) **
Payment status	Free	85	30	3.96(2.47–6.37) *	2.38(1.36–4.18) **
Payment status	Paid	128	179	1	1

HF, health facility; * Variables significant in binary logistic regression; ** Variables significant in multivariate logistic regression; COR, crude odd ratio; AOR, adjusted odd ratio; 1-reference group

The overall quality of YFS at public health facilities in Debre Birhan was 54.2%, which was below the cutoff point (75%) of the WHO standards. This finding is consistent with the quality assessment reports from the Oromia region in Sendafa, west Gojjam, and northeastern Ethiopia in Dehana district (35–37), where the quality of YFS was “below the standard of care or not good.

The structural quality of YFS was 70.7%, indicating poor quality. The findings are higher than those from Arbaminch (54.41%), Dehana district (58.8%), and west Gojjam (61.1%) (34–36). A possible reason for the higher findings of the current study could be the variation in study settings and the presence of nos in the study area.

On the other hand, the current finding is lower than that of a study conducted in the Oromia region of Ethiopia (76.6%) (35). This difference could be due to differences in the structural quality measurement items and a lack of resources and competing health priorities in the study area. The findings indicate that inadequate health worker training, shortages, and stockouts of essential drugs and supplies, a lack of youth-separated waiting rooms because of budget constraints, and the absence of peer educators compromise the structural quality of YFHS.

This study also showed that the YFHS data were not available during the weekend or late afternoon. As most service users are students, it may be difficult for young people to obtain health services if working hours coincide with school hours. The findings are consistent with similar studies conducted in Arbaminch town and Dehana district, Ethiopia (34, 37).

In addition, this study showed that none of the health facilities in the town have working guidelines, protocols, or standard operating procedures (sops) on the YFHS provision because they are not distributed from the town’s health office. The lack of guidelines, protocols, and policies, combined with insufficient training in YFHS, may significantly affect the quality of services. The findings are consistent with those of a previous study, which showed that all facilities lack YFHS policies, procedures, and protocols (34).

The process quality of the YFS was 41.3%, indicating poor quality. The findings are similar to those of a study conducted in southern Ethiopia (42%; 34) and consistent with a study conducted in Dehana district, Ethiopia (46.4%; 37). On the other hand, the findings were consistent but higher than those of a study conducted in the Oromia region at Sendafa (28%; 35). This difference could be due to the differences in the technical skills and competency of the service providers assigned at the YFS Corner. Moreover, the process quality was affected by inadequate privacy and confidentiality issues (related to multiple interruptions and absence of screens in the examination room and performing physical examinations without the permission of the client) and a poor communication system between the provider and client (low psychosocial assessment, no information provided on the available services, low use of audio-visual material, and not using job aids).

In this study, the outcome quality (client satisfaction) of YFS was 50.5%, which is below the standard of care. This finding is consistent with a study on youth client satisfaction in southern Ethiopia at 49.1% (34), northeastern Ethiopia at Dehana district at 47.2% (37) and Iran at Kerman hospital at 49.6% (45). However, the satisfaction level was lower than that of studies conducted in South Africa (81.7%) (46), the Oromia region at Sendafa 70.3% (35), Dejen district, Ethiopia 60.7% (47) and Dessie town 58.9% (39). A possible explanation for this difference may be the differences in the service delivery quality, study area and client expectations.

The client age was significantly associated with YFS client satisfaction; clients within the age group of 15–19 were 69% less likely to be satisfied with YFS compared to those within the age group of 20–24 years. This finding is consistent with that of a study conducted in the Oromia region, Ethiopia (35), and Mongolia (48), which revealed lesser satisfaction among younger adolescents. This decrease in satisfaction could be related to younger adolescents being ashamed and afraid to ask for the services they want because they are less exposed to reproductive health-related issues. On the contrary, a study conducted in southern Ethiopia showed that the age group of 15–19 was 3.2 times more likely to be satisfied with YFS compared to those in the age group of 20–24 years (34). This variation may be due to differences in sociocultural factors.

Another predictor variable that showed a significant association in this study was the sex of the service provider. Clients who were not comfortable with sex of service providers were 63% less likely to be satisfied with YFS than clients who were comfortable with sex of service providers. This finding is comparable with the study conducted in Southern Ethiopia: clients who were not comfortable with the provider’s sex were 93% less likely to be satisfied with YFS compared with those who were comfortable (34). At Sendafa, clients who were not comfortable with care providers were 90% less satisfied compared with their counterparts (35). This may be because clients who do not meet their sex preferences will not be happy and may encounter problems in freely discussing their issue with the service providers.

In addition, clients who waited less than 30 minutes and waited from 30 minutes to one hour were 4.58 and 3.65 times more likely to be satisfied with YFS than those who waited more than one hour. This finding is supported by a similar study conducted in different areas of the country: southern Ethiopia (34), northeastern Ethiopia at Dehana district (37), the West Amhara region (40), and Jimma University specialized hospital (49). This can be attributed to the high client load and insufficient assignment of YFHS providers to public health facilities. This may also be due to the limited awareness of service users who recognize that certain healthcare services require time to provide quality service.

Furthermore, clients who received YFHS services free of charge were 2.38 times more likely to be satisfied than those who paid for YFHS services. The findings are consistent with a study conducted in Dehana district, Ethiopia (37) and the West Amhara region, Ethiopia (40). This may be attributed to the fact that the financial capacity to pursue YFHS and high medical costs may not be convenient for adolescents and youths.

Conclusion

By taking into account all quality dimensions using the Donabedian quality assessment framework, in which structural (input), process, and output (client satisfaction), the study findings generally showed that the overall quality of youth-friendly health services was categorized as not good or below the standard (35, 43).

The study also shows that age, waiting time for a health care provider, payment status, comfort with the sex of the service providers, and payment status of the clients are independent predictors of client satisfaction with youth-friendly health services.

Recommendation

Based on the findings, the following recommendations were forwarded to facility administrators and healthcare providers:

Providing capacity-building training for service providers to increase their competency and technical skills, especially how to communicate and approach young people clients at YFS corners.
Prepare and distribute guidelines and protocols; build youth waiting rooms; and avail IEC-BCC materials and procedures essential to YFHS delivery.
Minimize and avoid shortages of supplies and drugs.
Involving adolescents and youth in the planning, implementation, and evaluation of youth-friendly health programs and services.
Reducing long waiting times for clients and providing adequate and trained providers should be assigned to healthcare facilities in YFHS rooms.
They should adhere to different YFS standards and guidelines.
Maintaining privacy and confidentiality-related issues for client

AIDS: Acquired Immunodeficiency Syndrome, AYSRH: Adolescent and Youth Sexual and Reproductive Health, HC: Health Center, HIV: Human Immunodeficiency Virus, HW: Health Worker, ICT: Information and Communications Technology, ICPD: International Conference on Population and Development, IEC: Information, Education, and Communication, LAFP: Long-Acting Family Planning, LMIC: Low- and Middle-Income Countries, MOH: Ministry of Health, NGO: Non-Governmental Organization, PAC: Post Abortion Care, RH: Reproductive Health, STIs: Sexually Transmitted Infections, SRH: Sexual and Reproductive Health, UNFPA: United Nations Population Fund, VCT: Voluntary, Counseling, and Testing, WHO: World Health Organization, YFS: Youth-Friendly Service.

Data sharing statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Consent for publication

Not applicable

Acknowledgment

We would like to thank Debre Berhan University, Asrat Woldeyes Health Science Campus, department of public health, participants, data collectors, and supervisors, to our friends and colleagues for their valuable support throughout the research process.

Funding

No external funding was received for the study

Disclosure of competing interests

The authors declare that they have no conflicts of interest for this work.

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Quality of youth friendly services at public health facilities in Debre Birhan Town: A mixed study

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Abstract

Figures

Introduction

Methods and materials

Study area, design, and period

Populations

Inclusion criteria

Sample size determination

Sampling techniques and procedures

Data collection tools and procedures

Operational definitions

Data management and analysis

Results

Sociodemographic characteristics of the participants

Structural quality of youth friendly health service

Process quality of youth friendly health service

Outcome quality of youth friendly service (client satisfaction, service utilization, and experiences)

Level of client satisfaction with YFS

Overall quality of youth-friendly services

Client satisfaction with youth friendly health service

Discussion

Conclusions and recommendations

Conclusion

Recommendation

Abbreviations

Declarations

Data sharing statement

Consent for publication

Acknowledgment

Funding

Disclosure of competing interests

References

Additional Declarations

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