One of the most critical and arguably fundamental areas of meeting the sexual and reproductive health needs of adolescents is the provision of a comprehensive adolescent-friendly sexual and reproductive health care service in health facilities. Most adolescents are in need of various SRH services and studies in Nigeria and India have shown they at times self-medicate or go to unqualified providers for help and may risk their health and lives as a result of unsafe practices.23,26Many reasons have been given for this concerning state of affairs with the extent of preparedness of health facilities to offer ASRH services critical to the utilization of the services by adolescents, and ultimately to the reduction and prevention of unintended teenage pregnancies and maternal mortality which are unacceptably high in Nigeria,27 as well as reduction of STI and HIV infections among adolescents.19 The aim of the current research was to assess the provision of ASRH services in health facilities in Plateau State, Nigeria, in the light of the national policy which entails that ASRH be integrated into PHC facilities across the country.
For SRH services to be adolescent friendly, several factors must be considered according to WHO guideline; availability of dedicated space and equipment for ASRH, availability of specific ASRH services, accessibility of ASRH services, appropriateness of ASRH services and the quality of ASRH services. The results of the assessment reported in this study revealed that overall, Plateau State is not meeting the minimum standard requirement for the provision of ASRH services. Overall, the PHCs across the three senatorial zones did not meet the affirmative criteria of the five domains. The national target of 50% PHCs providing adolescent-friendly SRH services was only met for the accessibility of ASRH in the central and southern zones, with the northern zone approaching this target. Similar results were seen in a survey conducted in other parts of Nigeria where health facilities had no dedicated space and equipment for ASRH and the facilities did not provide specific ASRH services
This finding is also in line with results of an assessment of adolescent and youth friendly health services in PHCs in two provinces in South Africa using a similar approach, which found that none of the primary health care facilities met the guideline standard for providing adolescent and youth friendly services.28In the present research, majority of the PHCs across the three zones did not meet basic requirements for provision of ASRH services. Facilities that were sampled in this study generally lack space and equipment for ASRH. For example, many of the facilities did not have dedicated space for consultation with adolescents, no waiting rooms to separate adult clients from adolescents and no dedicated examination rooms for adolescents. The equipment were all adult sizes, they lacked sphygmomanometer with the cuff for adolescents and no adolescent size speculum for vagina examination. Traditionally, health facilities in Nigeria are designed for adults, with no consideration for adolescents: Many of the facilities lack separate spaces for adolescents, no waiting room to separate adult clients from adolescents and no separate examination room for adolescents.21, 22
The provision of essential ASRH services was below the benchmark stipulated by the national policy. Very few PHCs in the three zones offer critical ASRH services such as counselling on sexuality, counselling on contraception, and counselling on safe sex/ STI prevention. Although family planning services were available in most facilities, these are usually not targeted at adolescents but married women. Generally, counselling on HIV testing scored above 50% across the zones. This is not surprising following the Government focus on HIV prevention and treatment which has driven so many non-governmental organizations to provide services targeted at HIV prevention in most facilities. This finding is a reflection of the assessment of youth friendly health services conducted in Nigeria, which also found that specific ASRH services such as counselling on safe sex and provision of contraceptive for adolescents were either not done or poorly provided in centres designated to do so.23, 24The worst of the services provided was that of counselling on gender base violence, probably because it is not recognized as a reproductive health problem but rather a domestic issue that should be handled privately at home.
Similar findings of low ASRH services were reported in a Ugandan and South African research, where specific ASRH services were poorly provided, except VCT for HIV that was fairly provided.20, 22 When ASRH services were compared across the zones, the southern zone had better scores in counselling for safe sex and post abortion care but the reason for the difference was not established in this study. It may probably be because the southern zone is more of a rural area, and perhaps the assumption that such areas are more in need of SRH care services, thereby attracting the concentration of some NGOs in that region.
The government of Nigeria has admitted in the national Policy22 that adolescent and Youth Friendly services are an integral part of the PHC System. These services should however be accessible to those who need it, while it was observed that most of the facilities were situated close to schools and where adolescents gather in the localities, which should have been a strength and opportunity to leverage on in reaching out to adolescents, that was not the case, as it was discovered that the opening and closing hours were not suited to adolescents’ needs in majority of the facilities. The facilities did not operate at hours convenient for adolescents (e.g. after school), and had no separate hours for adolescent counselling. Again, the Southern zone did significantly better in this area compared to the other zones but still below 50%. Studies have demonstrated that adolescents have preferred hours for visiting health facilities, usually when adults are not around because of privacy and confidentiality.15, 28they usually will not like to discuss their sexual issues where adults will hear. Indeed, the lack of privacy was reported in Tanzania as one of the reasons for poor utilization of health facilities especially for SRH services by adolescents.15, 29
One important approach to meeting the SRH needs of adolescents is through health education carried out by health care providers, this was lacking in almost all the PHCs. There were no appropriate SRH health education materials like posters, no peer educators and therefore peer education was not done in most of the facilities. Once more, this was better done in the Southern zone compared to the others. Outreach services have been identified as an approach with great impact in meeting adolescent with SRH services bearing in mind that they value confidentiality and most will not want their parents to know they access such services.30, 31,32Unfortunately, not many health facilities across the state were utilizing the opportunity, despite the proximity of the health facilities to adolescents.
It is important that the health care providers are knowledgeable about ASRH and that there is a standard policy guideline to enable quality delivery of information and services to adolescents. Unfortunately, this was lacking across the three senatorial zones. Very few facilities had staff trained specifically on delivery of ASRH especially in the central zone. This scenario was also reported in the studies conducted in Tanzania and Nepal where lack of qualified staff affected the utilization of SRH services.30,33,34,35 Achieving a meaningful reduction in adolescent sexual and reproductive health challenges faced by the country will require an urgent intervention in the area of training of health care providers which should be backed with a standard management guideline and procedure that should be available in all the health care facilities
Although it is argued that the health system component is not the only aspect affecting the sexual and reproductive health of adolescents, the lack of such structure contributes to the poor sexual and reproductive health challenges of adolescents in Nigeria.
This study was just limited to public primary health care facilities and did not explore the private health facilities, perhaps some private health facilities may have ASRH friendly services in place. It would have been more holistic to assess all categories of health facilities.