Article

Adolescents perception of reproductive health care services in Sri Lanka

National Institute of Health Sciences, Sri Lanka, Kalutara South, Western, Sri Lanka
BMC Health Services Research (Impact Factor: 1.71). 02/2008; 8(1):98. DOI: 10.1186/1472-6963-8-98
Source: PubMed

ABSTRACT

Adolescent health needs, behaviours and expectations are unique and routine health care services are not well geared to provide these services. The purpose of this study was to explore the perceived reproductive health problems, health seeking behaviors, knowledge about available services and barriers to reach services among a group of adolescents in Sri Lanka in order to improve reproductive health service delivery.
This qualitative study was conducted in a semi urban setting in Sri Lanka. A convenient sample of 32 adolescents between 17-19 years of age participated in four focus group discussions. Participants were selected from four midwife areas. A pre-tested focus group guide was used for data collection. Male and female facilitators conducted discussions separately with young males and females. All tape-recorded data was fully transcribed and thematic analysis was done.
Psychological distresses due to various reasons and problems regarding menstrual cycle and masturbation were reported as the commonest health problems. Knowledge on existing services was very poor and boys were totally unaware of youth health services available through the public health system. On reproductive Health Matters, girls mainly sought help from friends whereas boys did not want to discuss their problems with anyone. Lack of availability of services was pointed out as the most important barrier in reaching the adolescent needs. Lack of access to reproductive health knowledge was an important reason for poor self-confidence among adolescents to discuss these matters. Lack of confidentiality, youth friendliness and accessibility of available services were other barriers discussed. Adolescents were happy to accept available services through public clinics and other health infrastructure for their services rather than other organizations. A demand was made for separate youth friendly services through medical practitioners.
Adolescent health services are inadequate and available services are not being delivered in an acceptable manner. Proper training of health care providers on youth friendly service provision is essential. A National level integrated health care program is needed for the adolescents.

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BMC Health Services Research
Open Access
Research article
Adolescents perception of reproductive health care services in Sri
Lanka
Suneth B Agampodi*
1
, Thilini C Agampodi
1
and Piyaseeli UKD
2
Address:
1
Medical officers of Health, Beruwala, Sri Lanka and
2
Director, National Institute of Health Sciences, Kalutara, Sri lanka
Email: Suneth B Agampodi* - sunethagampodi@yahoo.com; Thilini C Agampodi - tagampodi@yahoo.com; Piyaseeli UKD - nihs@sltnet.lk
* Corresponding author
Abstract
Background: Adolescent health needs, behaviours and expectations are unique and routine
health care services are not well geared to provide these services. The purpose of this study was
to explore the perceived reproductive health problems, health seeking behaviors, knowledge about
available services and barriers to reach services among a group of adolescents in Sri Lanka in order
to improve reproductive health service delivery.
Methods: This qualitative study was conducted in a semi urban setting in Sri Lanka. A convenient
sample of 32 adolescents between 17–19 years of age participated in four focus group discussions.
Participants were selected from four midwife areas. A pre-tested focus group guide was used for
data collection. Male and female facilitators conducted discussions separately with young males and
females. All tape-recorded data was fully transcribed and thematic analysis was done.
Results: Psychological distresses due to various reasons and problems regarding menstrual cycle
and masturbation were reported as the commonest health problems. Knowledge on existing
services was very poor and boys were totally unaware of youth health services available through
the public health system. On reproductive Health Matters, girls mainly sought help from friends
whereas boys did not want to discuss their problems with anyone. Lack of availability of services
was pointed out as the most important barrier in reaching the adolescent needs. Lack of access to
reproductive health knowledge was an important reason for poor self-confidence among
adolescents to discuss these matters. Lack of confidentiality, youth friendliness and accessibility of
available services were other barriers discussed. Adolescents were happy to accept available
services through public clinics and other health infrastructure for their services rather than other
organizations. A demand was made for separate youth friendly services through medical
practitioners.
Conclusions and recommendations: Adolescent health services are inadequate and available
services are not being delivered in an acceptable manner. Proper training of health care providers
on youth friendly service provision is essential. A National level integrated health care program is
needed for the adolescents.
Published: 3 May 2008
BMC Health Services Research 2008, 8:98 doi:10.1186/1472-6963-8-98
Received: 9 September 2007
Accepted: 3 May 2008
This article is available from: http://www.biomedcentral.com/1472-6963/8/98
© 2008 Agampodi et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Background
Adolescence is stated as the period of transition from
childhood to adulthood, which starts with the onset of
puberty. It comprises the individuals between the ages of
ten to nineteen years. During this important period, a
child undergoes biological transition, which is character-
ized by puberty, related changes in physical appearance
and the attainment of reproductive capability, psycholog-
ical or cognitive transition, which reflects an individuals
thinking, and social transition, which is related to rights,
privileges and responsibilities of an individual[1].
In Sri Lanka, adolescents represent 22% of the total popu-
lation[2]. School participation of the adolescents in 14–
19 age group is around 55%[3]. The median age of mar-
riage among Sri Lankan women has increased by almost
seven years from 18.1 to 24.6 during the last century[2].
Data on unwanted pregnancies and abortions are not
properly reported in Sri Lanka. However, studies have
shown that young people in the 15–25 age group
accounted for 19% of the illegal abortions that are taking
place in the country[4,5]. The knowledge on available
contraceptive methods are fairly high, and the use of con-
traceptive methods among married adolescents is around
65% [2]. Among unmarried adolescents the usage is not
properly studied and there is a great paucity of data[6].
Premarital sex is not culturally accepted in Sri Lanka. But,
in the country the sexual debut for both females and
males is found to be around 15 years [7]. Prevalence of
sexual activities (penetrative and non-penetrative sex)
among school children is as high as 10.2% and among out
of school adolescents it is 22.2%[7]. The 30000 estimated
commercial sex workers [6] and the clearly reported low
condom use [8] also increases the risk of transmission of
HIV and STI. All these risk factors and low level of knowl-
edge among adolescents, especially about transmission of
HIV and STI [9] make young people more vulnerable for
all kinds of Reproductive Health (RH) problems.
RH services in Sri Lanka are delivered as an integrated part
of the family health program. The family health service
delivery is conducted through the Medical Officer of
Health (MOH) system where a community physician is in
charge of a particular area. Average population covered by
an MOH is around 60 000. An MOH area is further
divided in to Public Health Midwife (PHM) areas where
the average population is around 3000. PHM provides all
family health services at the grassroots level, for her area.
The RH services in the family health program are tradi-
tionally targeted on married couples. However, RH serv-
ices are available for those who seeks help through PHM,
MOH, MOH clinics, youth corners in selected major hos-
pitals and few Youth friendly Health Service (YFHS) cen-
tres. Availability of RH services is not adequate and even
the places where such facilities are available are not acces-
sible to those who really need the services[6]. Although
some RH programmes targeted on the school children
were carried out during the past few years, the most vul-
nerable population of recent school leavers is often being
neglected[9].
Integrated services delivered through the healthcare sys-
tem are identified as one of the most effective ways of
delivering RH services [10]. This is a huge challenge in
countries like Sri Lanka due to various cultural and social
barriers. It is important that this service integration should
be done in a very careful manner without disrupting the
available system. In order to provide acceptable services
with adequate utilization, in-depth exploration of social
and cultural barriers and understanding the needs and
expectations of adolescents is a great necessity.
This study intended to explore the perceived reproductive
health problems, health seeking behaviors, knowledge
about available services and barriers to access such serv-
ices among adolescents in Sri Lanka. This would then help
to develop and improve the delivery of existing adolescent
RH services in a more efficient manner.
Methods
Study settings
Present study was conducted from March to May 2007 in
the MOH area Beruwala, which is situated in the Kalutara
district of Western province, Sri Lanka. The area is divided
in to 47 PHM areas, each PHM area having around 3000
population each.
The area is vulnerable for RH problems, tourism being
one of the major income sources in the area[11]. A consid-
erable number of youth towards the coast tends to earn
their living by serving as beach boys (Men having sex with
men)[12]. Internally displaced people due to Tsunami
and large-scale Tsunami constructions which causes inter-
nal migration of young workers to this area also contrib-
utes to the higher risk taking behaviours and vulnerability
regarding RH issues (personal observations by authors as
service providers). A YFHS project is currently being car-
ried out in the area as a pilot project. Awareness raising
and knowledge improvement was the main target in the
first phase of the project. The next phase would be the
integration of YFHS activities in to the present public
health system in order to provide RH services in a more
efficient manner.
Study design
Authors used a qualitative method for understanding ado-
lescents' perspectives on RH services. Traditionally used
quantitative methods are unable to provide real life data
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on needs, believes, attitudes, and values of various popu-
lation groups. Qualitative methods provides 'real life"
rather than experimental or control views of past phe-
nomena [13]. Authors used Focus Group Discussions
(FGD) to achieve the study objectives. FGDs are widely
used in exploring people's behaviours, perceptions, atti-
tudes healthcare needs [14-18] and barriers to health serv-
ices [18-20] in relation to RH.
Participants
Adolescents aged 17 to 19 years and residing in the MOH
area Beruwala participated in the study. The particular age
group was selected as it covers both schooling and non-
schooling populations. The school drop out rate in the
area was highest after grade 10, which is around the age of
16 years.
Sampling and recruitment of participants
Participants were selected from four PHM areas. Conven-
ience sampling procedure was carried out to select these
four PHM areas. Three PHM areas had local youth clubs,
while the fourth had a local sports club. One research
assistant contacted a member of each of these clubs and
detailed him or her on the objectives of the research. The
selected youth provided a list of eligible participants from
the area. Eligible participants were those who belonged to
the 17–19 year age group and have residing in the partic-
ular PHM area. The PHM and a research assistant visited
these families, explained the nature of the study, and
invited the subjects for the FGDs. All parents were pro-
vided with written information concerning the study and
written consent was obtained. Each focus group had 6–11
Participants. Although most of the respondents were
known to the PHM, there was no professional-client rela-
tionship between the investigators and the respondents
prior to the study. Participants who were relatives of
healthcare workers were excluded.
Procedure
An interviewer guide was developed with the help of a
Consultant Community Physician, a youth counsellor, a
reproductive health physician and two Community physi-
cians working in the study area. The Guide was developed
in Sinhalese as the FGDs were conducted in the Sinhala
language. Probing questions were also developed to
explore RH problems. The guide consisted of open-ended
questions related to broad subject areas of, perceived
health problems, help seeking behaviour, knowledge on
available RH services, barriers to reach such services and
expectations of adolescents. Data collectors were trained
according to the guidelines given by family health interna-
tional on qualitative research[21]. The principal investiga-
tor (male) and a male research assistant conducted the
FGDs for boys and a female investigator and a female
research assistant conducted the FGDs for girls. The sub-
jects and investigators were of the same sex to overcome
the strong cultural barriers on discussion of reproductive
and sexual health problems.
Discussions were carried out in places chosen by the par-
ticipants. Each discussion lasted around one and half
hours. At the end of the session, a summary of the
recorded data was presented to participants and clarifica-
tions and corrections were made.
Analysis of data
Tape-recorded data were fully transcribed and analysed
manually. Thematic analysis was done to achieve study
objectives. All transcripts were read several times by the
investigators separately to bring out the main ideas, barri-
ers and beliefs of participants. Then discussions among
investigators were held to achieve common consensus on
the most prevalent attitudes, barriers and beliefs expressed
in each group. These themes were categorised according to
perceived health problems, knowledge on available serv-
ices, barriers to reach services, attitudes towards available
services and expectations. Thematic analysis was per-
formed and quotations were taken with common consen-
sus of the group of investigators.
Ethical and administrative considerations
Ethical clearance for the study was taken from the Ethical
Review Committee, University of Colombo. Each partici-
pant and their parents were first provided with an expla-
nation of the purpose, general content, and time
commitment involved in participating in the discussion,
and assurance of confidentiality. Informed written con-
sent was obtained from each participant prior to discus-
sions.
As the study involved discussion of sensitive issues, which
could lead to further distress of the adolescents who are
having problems, individual discussions and counselling
services were offered to all participants after the discus-
sions.
Results
Altogether 32 adolescents participated in the discussions.
The sample consisted of 13 males and 19 females. All of
whom were between 17 to 19 years of age and had com-
pleted at least primary education. All were unmarried and
19 of them were still schooling. Three males were
employed while 10 in the final sample had just finished
school.
Perceived health problems among adolescents
Common problems
Perceived problems among adolescent boys and girls dif-
fered. Both girls and boys reported that the most fre-
quently encountered problems have lead to the
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development of psychological distresses among them.
Love affaires, stresses due to exams, conflict of ideas with
parents, lack of proper love and care by the family and
lack of job opportunities were the main causes for psycho-
logical distress. Conflicts of ideas with parents were the
main problem reported by the boys. Some explained that
such conflicts were mainly due to the difference educa-
tional level between the younger generation and their par-
ents.
"Most of my friends are educated at least up to grade eight,
while their parents had gone only up to grade five. So they can't
understand what their children are doing"
(18-year-old boy)
Both boys and girls discussed substance abuse as a prevail-
ing problem among their friends. Some boys reported
smoking and alcohol use as problems only among some
groups. Furthermore, they also indicated that psychologi-
cal disturbances due to masturbation, body shape and
acne were also frequently discussed among their peers.
Reproductive health problems
Initially the girls were reluctant to reveal their RH prob-
lems. Eventually they came to a general agreement that
problems regarding menstrual cycle were the commonest
reproductive health problem among them. They also indi-
cated that sexual harassment in many forms was another
serious problem faced by them. Girls were agitated when
they discussed this issue and the majority of them agreed
that this had happened to them at least once, and mostly
during public transportation (unwanted sexual touching)
and in public places (verbal harassment) by unknown
people.
Among the boys, the main RH problem discussed related
to masturbation. Some forms of sexual harassment were
also reported. However, boys faced these harassments
usually from people known to them.
Adolescents' health seeking behaviours
In all FGDs, the adolescents agreed that friends were the
first contact person for most of their health problems.
Girls generally preferred advice from the mother espe-
cially for minor problems. Few girls indicated that they
could discuss any matter with their mothers while the
majority sought advice from their best friends. Only one
participant reported that she could discuss reproductive
health problems with a teacher. Nevertheless, most of the
adolescent girls disagreed and said that they had no trust
in teachers regarding these matters.
Boys agreed unanimously that they did not discuss these
problems with parents or teachers. They described that,
for minor problems they consulted their friends. How-
ever, for major problems they hesitated to consult even
their friends.
According to the adolescent boys, marginalization and
bulling among peer groups was very common, which was
the reason why they did not want to be come out with
such problems.
"They may be friends, but you know we can't trust friends on
this kind of matters, better to keep it to your self"
(18-year-old young male)
"You can forward the problem to your friends pretending that
it has happened to one of your friends. Then they discuss it and
you can get a clue to what to do"
(17-year-young male)
Both boys and girls consistently described that parents
always take them to private practitioners (allopathic) for
RH problems. None of the subjects had experienced other
types of therapies. The participants did not discuss the use
of home remedies and traditional medicine.
Knowledge about available services
Knowledge on available services was very poor among
adolescents. Only girls had heard about the availability of
the PHM for their services at their doorstep. Not a single
boy knew that they could seek help from the PHM or from
MOH clinics for their RH problems. They were totally
unaware of the availability of the youth corner in the
nearby general hospital, and only two girls knew the avail-
ability of the youth friendly health services centre. None
of them had visited this centre. Some boys complained
that they are discriminated by the health care providers
and policy makers.
"Girls have various services and clinics at least twice a month
in the village clinic centre. They also have clinics and specialists
in hospitals for them. We boys do not have a single service,
place or a person to discuss our problems"
(17-year-old young male)
Barriers to reach services
Lack of services
The main barrier for the adolescents was the unavailabil-
ity of RH services. All participants agreed to this without
any argument. They blamed health care providers, parents
and all adults for neglecting them. Boys had more exam-
ples to report and they were frustrated about the lack of
services.
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"No one cares about boys, but we have problems to discuss. We
don't know whether these health care workers are good at solv-
ing our problems. The way they treat other illnesses made me
feel uncomfortable to discuss sensitive reproductive issues with
them"
(17-year-young male)
"They think we are healthy, but we have problems and we need
answers"
(19-year-young male)
Privacy and confidentiality concerns
Both boys and girls recognized lack of self-confidence and
shyness as barriers in seeking help. Some of the adoles-
cents explained that it was the main barrier for them to
seek the services. Among girls, lack of confidence was
accentuated due to the inadequate privacy and confiden-
tiality given by health care providers, teachers and parents
for these issues.
"Doctor asked me embarrassing questions in front of my
mother. As soon as we left the place she started asking me var-
ious questions with a tone of blaming; I decided not to seek
medical advice again and not to tell anything to my mother"
(18-year-old girl)
"If you discuss these things, the principle and elder teachers will
discriminate you in school"
(17-year-old young female)
However, among boys, the impression of parents and
teachers was not a problem but the major concern was
about marginalization from their peer groups.
"They will laugh at me if I seek medical advice for this kind of
thing."
(17-year-old young male)
"I can't go to my friends again if they get to know about this"
(17-year-old young male)
Lack of knowledge and information
The groups pointed out how the lack of knowledge on RH
among them had led to a lack of confidence in solving
these problems. They described that information on
reproductive and sexual health was deliberately made
unavailable for them by their parents and their teachers.
They thought that most of these obstacles would have
been avoided if they were well aware of these issuse. They
felt that these topics are usually kept away from them in
schools and libraries. Even though they had some sources
of information, they were not exposed to these at their
correct age.
"Two of my friends (both girls) ran away from home at the age
of 14 and had a pregnancy with severe complications. They got
to know about these things (even about sex) only after delivery
of the baby. They did not have a clue about becoming pregnant
with such an act. By that time even we didn't know exactly
what was happening"
(18-year-old young female)
Girls totally agreed with the above statement and most of
them had similar stories to tell. They were in the opinion
that RH education should start at least from age 13
onwards.
"If you want to get the real picture, you go and have a discus-
sion with children in grades 7 and 8, not with us" was one
comment received from an adolescent girl.
Attitudes of health care providers was another problem
emphasized by the adolescents. They totally refused to go
to crowded public clinics to discuss RH problems.
"The doctor and the attendant are very busy to clear off the
crowd. If you start long stories, they will ask you to cut it short.
How can you cut it short when you do not know even how to
start the story?"
(19-year-old young female)
The adolescents were not happy even with present service
of general practitioners. The majority of the participants
were of opinion that doctors were not providing adequate
information. Need for information was mentioned
mainly in the male FGDs. The boys had numerous exam-
ples to elaborate their experiences.
"When doctor treated me for mumps, I was so worried about
impotence and infertility; that's what I heard from my friends,
but he didn't spoke a word about complications"
(18-year-old young male)
Attitudes of parents
Negative attitudes of parents, teachers and society were
another barrier recognized by the adolescents, mostly by
the girls. They reported that most of their mothers treated
them as small kids. Some adolescent girls added that
engaging in sex early in life was not a problem for some of
the parents. Parents just tried to get rid of the girls by
allowing them to practice sex and thereafter by allowing
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them to proceed with teenage marriages. They (adoles-
cents) only realized that they had done a mistake when
they reach their twenties. Most girls accepted this blame
and they thought that the parents were responsible for
problems related to early sex and marriages. However,
boys had a rather different opinion and they said adoles-
cents themselves were responsible for such acts.
Adolescents' expectations
All participants agreed that improving awareness on RH
among their age group would be a main strategy in
increasing service utilization by them. Girls suggested on
improving awareness among teachers and parents as well.
Furthermore, they appealed for continuous, effective
advocacy programmes. However, boys stressed that they
needed more knowledge for themselves. They had no
claim in creating awareness among parents and teachers.
"It is good that if someone can come to the house and speak on
these things when parents and every body is there"
(18-year-old young female)
"Whether you educate them (parents) or not, we are not going
to discuss these matters with them. Instead give us knowledge
and provide us with services, so that we can manage these prob-
lems"
(18 years old young male)
Need for well-trained health care providers
The adolescents emphasized that health personnel should
be the ones to inform adolescents. Trained volunteers and
other trained personnel (such as teachers) were not con-
sidered good enough. Service of the PHM was somewhat
appreciated by girls and some of them were ready to con-
tact the PHM for these services, if the PHM was willing to
provide the services in a confidential manner. This would
be a better choice as the PHM was already trusted and
appreciated by their parents and therefore the girls could
visit the PHM without any obstruction from their parents.
However, they had some doubts regarding confidential-
ity.
"She (PHM) is providing care only for pregnant mothers, so
that, people will think that I'm pregnant and hiding some-
thing"
(17-year-old young female)
Boys totally refused the service of midwives. They
demanded for a young male doctor. Some of the girls also
preferred a doctor.
"If you tell the whole story to the PHM, she will refer you to a
doctor. Then we should repeat the same embarrassing story once
again. Why not have a direct contact with a doctor"
(19-year-old young female)
In all FGDs the need for a doctor who could listen and
understand their problems was mentioned. The girls liked
to have an outsider to provide these services and some
wanted a female doctor. However, some said that even
male doctors would be very helpful.
"We are used to male doctors in private places so that it doesn't
matter as long as they are helpful"
(18-year-old young female)
Need for special clinics
Use of existing clinics to provide adolescent health serv-
ices was accepted by the majority of adolescent. Few girls
explained that it was embarrassing for them to come to
clinics, but others described that it was the ideal place.
They said that those public clinics were safer and their par-
ents' attitudes towards public clinics were favourable.
"My mother will send me here but not to other places, especially
to discuss reproductive health matters"
(17-year-old young female)
Both boys and girls mentioned hat they needed special
clinics in evenings or weekends. Most of them refused to
come for services daytime (even for a separate session)
when maternal and child clinics were conducted. The
boys explained that they needed separate sessions without
girls and they liked to have services on a different day.
Discussion
This study provides an overview of adolescents' perceived
reproductive health problems, health seeking behaviors,
knowledge about available services and barriers to reach
services in semi urban Sri Lankan context. Even though
evidence is abundant through a decade of research on this
subject [22], country and area specific problems should be
investigated to provide services in a more acceptable man-
ner. In Sri Lanka, few studies have attempted to explore
qualitative aspects of adolescent health care needs and
their perceived barriers [6].
Most of he current study findings are in parallel with other
studies all over the world [22] But, some problems identi-
fied by the adolescents were unique to our study. Unlike
previous findings, adolescents' major problem was psy-
chological disturbances due to conflict with parents. Even
health seeking behaviours were somewhat different from
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other settings. Evidence from developing and developed
countries suggests that most of the adolescents seek help
from friends and family[14]. However, this study sample
was more internalized and, stigmatization from peers was
one of their major concerns. Therefore, they were not will-
ing to seek help from family and friends.
The negative attitude towards involving parents and
teachers might be a sign of rapidly deteriorating family
environment, especially for boys. This should be
addressed immediately since parent child connectedness
being one of the major determinants of adolescent health
and risk taking behaviour [23-25].
Reported barriers to RH services was extensively discussed
and highlighted repeatedly through the discussions.
Availability, accessibility, acceptability, confidentiality
and even lack of publicity and visibility of available serv-
ices were the main barriers. These barriers have been rec-
ognized as universal barriers to adolescent health[26].
Need for reproductive health education was highlighted
as a major step to remove these barriers. Although the
adolescents in this study appealed for community based
educational programmes through health care personnel,
which was mainly due to the lack of confidence in teach-
ers, evidence suggest that curriculum based sexual educa-
tion show promising results on preventing adverse
outcomes of adolescent RH problems [27,28]. So curricu-
lum based programmes are needed, but it is also impor-
tant to train teachers to tackle these sensitive issues in
order to gain adolescents confidence.
Use of existing public health care infrastructure for adoles-
cent health care services is a good strategy, considering the
reported positive attitudes of adolescents. A recent review
done by WHO has shown that this strategy was more suc-
cessful than other strategies for RH service provision [29].
Acceptance of PHM as a service provider by adolescent
girls is an encouraging sign. Improvement of confidential
care and training in youth friendly service provision
should, however, be encouraged. The 'family health
worker" concept in Sri Lankan public health service,
which is basically build upon maternal and child health
care, can be widened by integrating RH concepts.
The biggest challenge for the effective implementation of
programs would be the service provision for adolescent
boys. With the context of family conflicts, lack of even
peer group support, a huge gap in service provision and
refusal of services available through the PHM, the situa-
tion is difficult. The only health care workers who could
be utilized for his purpose would be the public health
inspectors. However, this will be a major challenge for the
public health service because at present the public health
inspectors are not widely accepted in community as "fam-
ily health workers". Adolescents' expectation of a trained
medical practitioner as the primary health care provider is
still not practicable. Initial contact point at grass root level
should be through highly trained family health workers.
Services provided by youth friendly health service centre
in the area are conceptually much in agreement with ado-
lescents' needs. Nevertheless, there is a need to improve
social marketing and accessibility of the services. Accord-
ing to the evidence available from previous studies[29]
and attitudes of adolescents reported from this study,
both sexes are not supportive of hospital-based services.
The youth corner concept in hospitals should be re-evalu-
ated and should be changed to provide more youth
friendly services.
The present study opens a huge area for further qualitative
research in order to gain more understanding of these
problems. Parent-child-family conflicts and its impact on
adolescent reproductive health is a priority area for stud-
ies.
The current study had several limitations. The number of
FGDs conducted was limited and they were confined to
the Sinhalese community only and the Muslim commu-
nity was not involved. Involvement of parents, teachers
and key informants (which was not done) would proba-
bly have given additional information in order to improve
services.
In conclusion, according to adolescents' perception on
availability, accessibility and acceptability of health serv-
ices, present health care system has failed to provide
appropriate services to them. Confidentiality and the
quality of care is a major concern among adolescents.
Planning of adolescents health care services should be ini-
tiated with participation of adolescents, so that the serv-
ices will be more user friendly. Program planning should
be based on qualitative studies in order to get a deeper
understanding.
Authors' contributions
SBA participated in the design, data collection, and man-
uscript preparation and performed the data analysis. TCA
participated in the design, data collection and manuscript
preparation. PUKD participated in design and helped to
draft the manuscript.
All authors read and approved the final manuscript.
Acknowledgements
We acknowledge the help of Palayangoda, Weragala, Aluthgama, Katuku-
rundugahalanda and Pothuwila PHMM and Aluthgama and Pothuwila public
health nursing sisters.
Page 7
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Pre-publication history
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    • "Adolescents need to have access to proven-effective sexual and reproductive health (SRH) interventions such as comprehensive sexual health education and counselling, access to condoms, contraceptives and HIV tests, especially in sub-Saharan Africa where rates of HIV and intimate partner violence (IPV) are high [1, 2] . Yet, globally young people face a range of barriers [3] at traditional health system facilities including cost [3], transportation, clinic hours [4] , privacy and confidentiality, lack of available services [5] and negative health worker attitudes [6]. Out-of-health facility approaches, which involve service provision at places where adolescents live and congregate such as youth centres and school-based approaches, are potentially important complementary strategies for increasing access to SRH services and education [3]. "
    [Show abstract] [Hide abstract] ABSTRACT: Adolescents need access to effective sexual and reproductive health (SRH) interventions, but face barriers accessing them through traditional health systems. School-based approaches might provide accessible, complementary strategies. We investigated whether a 21-session after-school SRH education programme and school health service attracted adolescents most at risk for adverse SRH outcomes and explored motivators for and barriers to attendance. Grade 8 adolescents (average age 13 years) from 20 schools in the intervention arm of an HIV prevention cluster randomised controlled trial in the Western Cape Province of South Africa, were invited to participate in an after-school SRH program and to attend school health services. Using a longitudinal design, we surveyed participants at baseline, measured their attendance at weekly after-school sessions for 6 months and surveyed them post-intervention. We examined factors associated with attendance using bivariate and multiple logistic and Poisson regression analyses, and through thematic analysis of qualitative data. The intervention was fully implemented in 18 schools with 1576 trial participants. The mean attendance of the 21-session SRH programme was 8.8 sessions (S.D. 7.5) among girls and 6.9 (S.D. 7.2) among boys. School health services were visited by 17.3 % (14.9 % of boys and 18.7 % of girls). Adolescents who had their sexual debut before baseline had a lower rate of session attendance compared with those who had not (6.3 vs 8.5, p < .001). Those who had been victims of sexual violence or intimate partner violence (IPV), and who had perpetrated IPV also had lower rates of attendance. Participants were motivated by a wish to receive new knowledge, life coaching and positive attitudes towards the intervention. The unavailability of safe transport and domestic responsibilities were the most common barriers to attendance. Only two participants cited negative attitudes about the intervention as the reason they did not attend. Reducing structural barriers to attendance, after-school interventions are likely to reach adolescents with proven-effective SRH interventions. However, special attention is required to reach vulnerable adolescents, through offering different delivery modalities, improving the school climate, and providing support for adolescents with mental health problems and neurodevelopmental academic problems. Current Controlled Trials ISRCTN56270821 ; Registered 13 February 2013.
    Full-text · Article · Jul 2015 · BMC Public Health
  • Source
    • "The higher participation in this study by young people from residential townships is probably justified by their relatively higher social living standard that might have facilitated the availability of call credit and the culture of listening to the radio in these areas. The focus on the menstrual cycle and masturbation intricates the youth in many developing countries such as Sri Lanka where similar preoccupations were expressed by both girls and boys [20]. In the DRC, young people are particularly concerned with different issues they are habitually deprived of during outreach activities in the community milieu. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: As teenagers have easy access to both radio programs and cell phones, the current study used these tools so that young people could anonymously identify questions about sex and other related concerns in the urban environment of the Democratic Republic of Congo. The purpose of this healthcare intervention was to identify and address concerns raised by young people, which are related to sexual health, and which promote youth health. Methods: This healthcare intervention was conducted over a six month period and consisted of a survey carried out in Kinshasa. This focused on 14 to 24 old young people using phone calls on a radio program raising concerns related to sexuality. The radio program was jointly run by a journalist and a health professional who were required to reply immediately to questions from young people. All sexual health concerns were recorded and analyzed. Results: Forty programs were broadcast in six months and 1,250 messages and calls were recorded: 880 (70%) from girls and 370 (30%) from boys, which represents an average of 32 interventions (of which 10 calls and 22 messages) per broadcast. Most questions came from 15-19- and 20-24-year-old girls and boys. Focus of girls' questions: menstrual cycle calculation and related concerns accounted for the majority (24%); sexual practices (16%), love relationships (15%) and virginity (14%). Boys' concerns are masturbation (and its consequences) (22%), sexual practices (19%), love relationships (18%) and worries about penis size (10%). Infections (genital and STI) and topics regarding HIV represent 9% and 4% of the questions asked by girls against 7% and 10% by boys. Concerns were mainly related to knowledge, attitudes and competences to be developed. Conclusions: Concerns and sexual practices raised by teens about their sexual and emotional life have inspired the design of a practical guide for youth self-training and have steered the second phase of this interactive program towards supporting their responsible sexuality.
    Full-text · Article · Jun 2014
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    • "Despite two decades of international research describing the barriers adolescents face accessing care, and global guidance on how these might be overcome, adolescents’ access to SRH services remains poor in many settings [16,17,23]. The need for context-specific research to support effective implementation of youth-friendly health services has been noted [24,25]. This study has identified key demand and supply-side barriers facing adolescents in Vanuatu and highlighted opportunities to increase accessibility and acceptability of SRH services. "
    [Show abstract] [Hide abstract] ABSTRACT: Sexual activity during adolescence is common in Vanuatu, however many adolescents lack access to sexual and reproductive health (SRH) services and subsequently suffer a disproportionate burden of poor SRH. There is limited peer-reviewed research describing adolescents' SRH service delivery preferences in Vanuatu to inform policy and programs. The aim of this qualitative study was to explore the barriers preventing adolescents from accessing SRH services in Vanuatu and the features of a youth-friendly health service as defined by adolescents. Sixty-six focus group discussions were conducted with 341 male and female adolescents aged 15--19 years in rural and urban communities. Additionally, 12 semi-structured interviews were undertaken with policymakers and service providers. Data were analysed using thematic analysis. Socio-cultural norms and taboos regarding adolescent sexual behaviour were the most significant factors preventing adolescents from accessing services. These contributed to adolescents' own fear and shame, judgmental attitudes of service providers, and disapproval from parents and community gate-keepers. Lack of confidentiality and privacy, costs, and adolescents' lack of SRH knowledge were also important barriers. Adolescents and service providers identified opportunities to make existing services more youth-friendly. The most important feature of a youth-friendly health service described by adolescents was a friendly service provider. Free or affordable services, reliable commodity supply, confidentiality and privacy were also key features. The need to address socio-cultural norms and community knowledge and attitudes was also highlighted. There are significant demand and supply-side barriers contributing to low utilisation of SRH services by adolescents in Vanuatu. However, there are many opportunities to make existing SRH services more youth-friendly, such as improving service provider training. Investment is also required in strategies that aim to create a more supportive environment for adolescent SRH.
    Full-text · Article · Oct 2013 · BMC Health Services Research
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