Improving the Quality of Adolescent and Youth-Friendly Health Services Through Integrated Supportive Supervision in Four Nigerian States.

BACKGROUND: Although the unique sexual and reproductive health needs of adolescents and youth (AY) are widely recognized, the challenge remains how to integrate adolescent- and youth-friendly health services (AYFHS) effectively within a systems-based approach that is both feasible and scalable. This article provides preliminary evidence from 4 Nigerian states that sought to overcome this challenge by implementing capacity-strengthening approaches centered around a shortened quality assurance (QA) tool that has become part of the state health system's routine supportive supervision process and follow-up quality improvement (QI) activities. METHODS: A shortened QA tool was administered to assess and track the performance of 130 high-volume health facilities across 5 domains to serve its AY population with quality contraceptive services. Facility-based providers (N=198) received training on adolescent and youth sexual and reproductive health, AYFHS, and long-acting reversible contraceptive methods. To corroborate checklist findings, we conducted exit interviews with 754 clients (aged 15-24 years) who accessed contraceptive services from the facilities that met the World Health Organization's minimum standards for quality AYFHS. RESULTS: In the 4 states, the QA tool was applied at baseline and 2 rounds, accompanied by QI capacity strengthening after each round. At baseline, only 12% of the 130 facilities in the 4 states scored met the minimum quality standards for AYFHS. After 2 rounds, 88% of the facilities met the minimum standards. AY client volume increased over this same period. All 4 states showed great improvements; however, the achievements varied by state. The exit interview feedback supported client satisfaction with the services provided to AY. CONCLUSION: Integrating QA followed by QI within Nigeria's family planning supportive supervision system is not only feasible but also impacts the quality of AYFHS and contraceptive uptake by clients aged 15-24 years.

Implementing Quality Improvement Initiatives to Improve the Use of Adolescent- and Youth-Friendly Health Services in Zou, Benin.

INTRODUCTION: In Benin, the unmet need for family planning services is especially high for adolescent girls and youth aged 15-24 years. The Challenge Initiative (TCI) supported the health system to assess and improve the quality of adolescent and youth sexual reproductive health services and enhance contraceptive uptake in 65 service delivery points (SDPs) of the Zou department. PROGRAM DESCRIPTION: Between June 2019 and March 2021, TCI supported the health districts in Zou to train an assessment team to complete 3 cycles of quality assessments (QAs) using a QA checklist adapted to the local context. Based on assessment scores, the SDPs were categorized into poor, moderate, or good to excellent quality. The SDP managers developed remedial action plans after each cycle and for each SDP and followed up with supportive supervision. RESULTS: The first QA cycle showed that 52% of assessed SDPs achieved a good to excellent classification; by the second QA cycle, this reached 74%. However, the quality of adolescent- and youth-friendly health services regressed during the third QA cycle (during COVID-19 pandemic disruptions), when only 40% of SDPs achieved the good to excellent category. Between the first and second QA cycles, contraceptive uptake for adolescents and youth improved in the SDPs that had good or excellent quality of services, compared to the ones that were of lower quality (established significance level of 5% with a P value of .031). CONCLUSION: Further assessments could deepen our understanding of the internal and external factors that can affect service quality. The findings reinforce the importance of investing in quality improvement strategies to maximize the use of sexual and reproductive health services among adolescents and youth. They also underscore the need for a contextual and nuanced approach to ensure enduring results.

ASRHR in Ethiopia: reviewing progress over the last 20 years and looking ahead to the next 10 years.

Over the last two decades, improvements in Ethiopia's socio-economic context, the prioritization of health and development in the national agenda, and ambitious national health and development policies and programmes have contributed to improvements in the living standards and well-being of the population as a whole including adolescents. Improvements have occurred in a number of health outcomes, for example reduction in levels of harmful practices i.e., in child marriage and female genital mutilation/cutting (FGM/C), reduction in adolescent childbearing, increase in positive health behaviours, for example adolescent contraceptive use, and maternal health care service use. However, this progress has been uneven. As we look to the next 10 years, Ethiopia must build on the progress made, and move ahead understanding and overcoming challenges and making full use of opportunities by (i) recommitting to strong political support for ASRHR policies and programmes and to sustaining this support in the next stage of policy and strategy development (ii) strengthening investment in and financing of interventions to meet the SRH needs of adolescents (iii) ensuring laws and policies are appropriately communicated, applied and monitored (iv) ensuring strategies are evidence-based and extend the availability of age-disaggregated data on SRHR, and that implementation of these strategies is managed well (v) enabling meaningful youth engagement by institutionalizing adolescent participation as an essential element of all programmes intended to benefit adolescents, and (vi) consolidating gains in the area of SRH while strategically broadening other areas without diluting the ASRHR focus.

Integrated Care Models and Child Health: A Meta-analysis.

CONTEXT: Integrated care models may improve health care for children and young people (CYP) with ongoing conditions. OBJECTIVE: To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions. DATA SOURCES: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996-2018). STUDY SELECTION: Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0-18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome. DATA EXTRACTION: Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care. RESULTS: Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03-0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57-1.37; P = .57). LIMITATIONS: Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist. CONCLUSIONS: Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.

How to measure the need for transition to adult services among young people with Attention Deficit Hyperactivity Disorder (ADHD): a comparison of surveillance versus case note review methods.

BACKGROUND: Health services have not provided adequate support for young people with long term health conditions to transfer from child to adult services. National Institute of Health and Care (NICE) guidance on transition has been issued to address these gaps. However, data are often sparse about the number of young adults who might need to transition. Using Attention Deficit Hyperactivity Disorder (ADHD) as an exemplar, this study used an existing surveillance system and a case note review to capture the incidence of the transition process, and compared and contrasted the findings. METHODS: The Child and Adolescent Psychiatry Surveillance System (CAPSS) was used to estimate the incident transition of young people with Attention Deficit Hyperactivity Disorder (ADHD) from child to adult services. This involves consultant child and adolescent psychiatrists from the United Kingdom (UK) and Republic of Ireland (ROI) reporting relevant young people as they are seen in clinics. In parallel, a case note review was conducted using the Maudsley Biomedical Research Centre (BRC) Clinical Records Interactive Search (CRIS). The study period ran for twelve months with a nine month follow up to see how the transition proceeded. RESULTS: CRIS identified 76 cases in the study period, compared to 18 identified using surveillance via CAPSS. Methodological issues were experienced using both methods. Surveillance issues; eligibility criteria confusion, reporting errors, incomplete questionnaires, difficulties contacting clinicians, and surveillance systems do not cover non-doctors and psychiatrists who are not consultants. Case note review issues using CRIS included the need for researchers to interpret clinical notes, the availability and completeness of data in the notes, and data limited to the catchment of one particular mental health trust. CONCLUSIONS: Both methods demonstrate strengths and weaknesses; the combination of both methods in the absence of strong routinely collected data, allowed a more robust estimate of the level of need for service planning and commissioning.

Helping Others: Reasons for Participation in Service User Involvement Initiatives from the Perspective of Adolescents and Young Adults with Cancer.

Purpose: Service user involvement, which implies involvement in decision-making processes important for organizing, developing, and evaluating health care, is sparsely investigated from the perspective of adolescents and young adults (AYAs) with cancer. Thus, the purpose of this qualitative study was to investigate AYAs' reasons for participation in service user involvement initiatives during their cancer course. Methods: Data from 12 semistructured interviews with AYA cancer patients and AYA cancer survivors aged 16-29 years were analyzed using thematic analysis. The participants had been involved in one or more service user involvement initiatives in "Kræftværket," a youth support center and social organization for AYAs with cancer in Copenhagen, Denmark. Results: Four main themes with matching subthemes were identified: Community (Being together, Developing together, and In the same boat), Normality (A new normal and Something to do), Contribution (Something at heart, Support to other AYAs, and Improving the health care system), and Codetermination (Real participation and Influence on one's own everyday life). Conclusion: Participating in service user involvement initiatives had a positive impact on the illness course of AYAs with cancer as the participation recreated a feeling of normality, codetermination of one's own everyday life, and met a wish for altruism in terms of helping others.

Child and adolescent health in Europe: monitoring implementation of policies and provision of services.

To promote children's health in Europe, the WHO Regional Office for Europe developed a strategy for child and adolescent health for the period 2015-20, which was adopted by all 53 European member states. The priorities of the strategy are broad and include action around supporting early childhood development, reducing exposure to violence, and tackling mental health problems in adolescence. The strategy's implementation was monitored with a survey of 82 questions sent to the ministries of health in all member states in 2016. Responses were received from 48 countries (91% of the region). Encouragingly, three-quarters of countries have either adopted or plan to develop a national child and adolescent health strategy. However, variation exists in the adoption of key components of the regional strategy and in the collection of data. For example, access to sexual and reproductive health services is unequal across the region, and childhood obesity and mental health are key areas of concern. Such survey data helps member states and the general public review achievements and address obstacles for children and adolescents realising their full potential for health, development, and wellbeing. The survey will be repeated in 2019 to identify subsequent changes in child and adolescent health in countries across Europe.

Assessment of adolescent and youth friendly services in primary healthcare facilities in two provinces in South Africa.

BACKGROUND: Health services for adolescents are increasingly recognised as a priority in low- and middle-income countries (LMICs). The Adolescent and Youth Friendly Service (AYFS) approach has been promoted in South Africa by the National Department of Health and partners, as a means of standardising the quality of adolescent health services in the country. The objective of this paper is to detail the evaluation of AYFS against defined standards to inform initiatives for strengthening these services. METHODS: A cross-sectional assessment of AYFS was carried out in 14 healthcare facilities in a sub-district of Gauteng Province and 16 in a sub-district in North West Province, South Africa. Data on adolescent care and service management systems were collected through interviews with healthcare providers, non-clinical staff and document review. Responses were scored using a tool based on national and World Health Organisation criteria for ten AYFS standards. RESULTS: Mean scores for the ten standards showed substantial variation across facilities in the two sub-Districts, with Gauteng Province scoring lower than the North West for 9 standards. The sub-district median for Gauteng was 38% and the North West 48%. In both provinces standards related to the general service delivery, such as Standards 4 and 5, scored above 75%. Assessment of services specifically addressing sexual, reproductive and mental health (Standard 3) showed that almost all these services were scored above 50%. Exploration of services related to psycho-social and physical assessments (Standard 8) demonstrated differences in the healthcare facilities' management of adolescents' presenting complaints and their comprehensive management including psycho-social status and risk profile. Additionally, none of the facilities in either sub-district was able to meet the minimum criteria for the five standards required for AYFS recognition. CONCLUSION: Facilities had the essential components for general service delivery in place, but adolescent-specific service provision was lacking. AYFS is a government priority, but additional support for facilities is needed to achieve the agreed standards. Meeting these standards could make a major contribution to securing adolescents' health, especially in preventing unintended pregnancies and HIV as well as improving psycho-social management.

Pediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey.

INTRODUCTION: The period of transition from pediatric to adult care has been associated with poor health outcomes among 10-19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria's estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV. MATERIALS AND METHODS: This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up. RESULTS: All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the "clinic type" question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services. CONCLUSIONS: Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.

Factors associated with pregnancy desire among adolescent women in five Latin American countries: a multilevel analysis.

OBJECTIVE: To explore demographic, socio-economic, and reproductive factors associated with pregnancy desire among adolescents in five Latin American countries. DESIGN: Secondary analysis using nationally representative, cross-sectional data from UNICEF Multiple Indicator Cluster Surveys (MICS). SETTING: Cuba, the Dominican Republic, El Salvador, Mexico, and Panama. POPULATION: Adolescents 15-19 years old who were pregnant or mothers (n = 4207). METHODS: Chi-square tests, simple linear regressions, and multilevel Poisson regression models were used to estimate associations between individual- and country-level factors associated with pregnancy desire among adolescents. MAIN OUTCOME MEASURES: Desire for pregnancy among adolescents who were pregnant or had given birth in the last 2 years. RESULTS: The proportion of adolescents who reported they desired their last pregnancy ranged from 79.3% in Cuba to 37.6% in Panama; approximately half the adolescents in Mexico, El Salvador, and the Dominican Republic desired their last pregnancy. The multilevel analysis shows that pregnancy desire was more likely among adolescent women who were less educated [prevalence ratio (PR) = 0.97, 95% confidence interval (CI) 0.96-0.98], older (PR = 1.39, 95% CI 1.04-1.09), married or cohabiting with a partner (PR = 0.70, 95% CI 0.53-0.93), and had low parity (PR = 0.67, 95% CI 0.58-0.76). CONCLUSIONS: Adolescents with less education, who are older, married or cohabiting, and with low parity were more likely to desire their pregnancy. These data constitute evidence that, in conjunction with qualitative and implementation research, can be used to better design services for adolescents so they can exercise their sexual and reproductive rights, and plan healthier and more satisfying futures. FUNDING: All the databases used on the performance of this study are open access. We did not receive any funding for the present analysis. TWEETABLE ABSTRACT: Parity and marital status showed the strongest association with adolescent pregnancy desire in five Latin American countries.

Inspectors' responses to adolescents' assessment of quality of care: a case study on involving adolescents in inspections.

BACKGROUND: Users of care services are increasingly participating in inspections of the quality of care. In practice, incorporating service users' views is difficult, as users may have other views on good care than inspectors and thus give information that does not fit the inspectors' assessment criteria. This study compared the views on good care of young care users (adolescents) and inspectors, seeking to understand what the differences and similarities mean to incorporating the users' views in inspections. METHODS: We conducted a single-case study combining document analysis with a meeting with inspectors. The selected case came from a Dutch inspectorate and involved a thematic inspection of care for children growing up poor. RESULTS: Inspectors and adolescents agree on the importance of timely care, creating opportunities for personal development, and a respectful relationship. The views on quality of care differ with regard to sharing information, creating solutions, and the right moment to offer help. We identified three ways inspectors deal with the differences: 1) prioritize their own views, 2) pass the problem onto others to solve, and 3) separate the differing perspectives. With similar viewpoints, inspectors use the adolescents' views to support their assessments. When viewpoints conflict, information from adolescents does not affect the inspectors' judgments. Explanations are related to the vulnerability of the adolescents involved, the inspectorate's organizational rules and routines and the external regulatory context. CONCLUSIONS: Service user involvement in inspections potentially impacts the quality of care. Yet, conflicts between the views of service users and inspectors are not easily overcome in the regulatory context.

Methodologic Considerations for Transition Research Using the National Survey of Children with Special Health Care Needs: A Systematic Review of the Literature.

The purpose of this review was to describe methodologic considerations in using the National Survey of Children With Special Health Care Needs (NS-CSHCN) for transition research in terms of variable inclusion and definition of transition outcomes and to provide suggestions for using NS-CSHCN for transition research. A systematic review was conducted. Inclusion criteria included use of NS-CSHCN data and transition as an outcome variable. Fourteen studies were included. Ten (71%) studies evaluated a sample of all CSHCN. Ten (71%) articles used all four variables recommended by the Maternal and Child Health Bureau core outcome on transition. Other variables included patient-centered medical home. The NS-CSHCN provides a rich dataset that can be used in transition research addressing transition preparation from the parent perspective. Using the NS-CSHCN, we recommend analyzing all variables related to the Maternal and Child Health Bureau core outcome for transition, variables related to patient-centered medical home, and further analysis of specific health conditions.

The no-go zone: a qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa.

BACKGROUND: Adolescents have significant sexual and reproductive health needs. However, complex legal frameworks, and social attitudes about adolescent sexuality, including the values of healthcare providers, govern adolescent access to sexual and reproductive health services. These laws and social attitudes are often antipathetic to sexual and gender minorities. Existing literature assumes that adolescents identify as heterosexual, and exclusively engage in (heteronormative) sexual activity with partners of the opposite sex/gender, so little is known about if and how the needs of sexual and gender minority adolescents are met. METHODS: In this article, we have analysed data from fifty in-depth qualitative interviews with representatives of organisations working with adolescents, sexual and gender minorities, and/or sexual and reproductive health and rights in Malawi, Mozambique, Namibia, Zambia and Zimbabwe. RESULTS: Sexual and gender minority adolescents in these countries experience double-marginalisation in pursuit of sexual and reproductive health services: as adolescents, they experience barriers to accessing LGBT organisations, who fear being painted as "homosexuality recruiters," whilst they are simultaneously excluded from heteronormative adolescent sexual and reproductive health services. Such barriers to services are equally attributable to the real and perceived criminalisation of consensual sexual behaviours between partners of the same sex/gender, regardless of their age. DISCUSSION/ CONCLUSION: The combination of laws which criminalise consensual same sex/gender activity and the social stigma towards sexual and gender minorities work to negate legal sexual and reproductive health services that may be provided. This is further compounded by age-related stigma regarding sexual activity amongst adolescents, effectively leaving sexual and gender minority adolescents without access to necessary information about their sexuality and sexual and reproductive health, and sexual and reproductive health services.

Determinants of adolescent pregnancy in sub-Saharan Africa: a systematic review.

BACKGROUND: Adolescent pregnancy has been persistently high in sub-Saharan Africa. The objective of this review is to identify factors influencing adolescent pregnancies in sub-Saharan Africa in order to design appropriate intervention program. METHODS: A search in MEDLINE, Scopus, Web of science, and Google Scholar databases with the following keywords: determinants, factors, reasons, sociocultural factors, adolescent pregnancy, unintended pregnancies, and sub- Saharan Africa. Qualitative and cross-sectional studies intended to assess factors influencing adolescent pregnancies as the primary outcome variable in sub- Saharan Africa were included. Our search was limited to, articles published from the year 2000 to 2017 in English. Twenty-four (24) original articles met the inclusion criteria. RESULTS: The study identified Sociocultural, environmental and Economic factors (Peer influence, unwanted sexual advances from adult males, coercive sexual relations, unequal gender power relations, poverty, religion, early marriage, lack of parental counseling and guidance, parental neglect, absence of affordable or free education, lack of comprehensive sexuality education, non-use of contraceptives, male's responsibility to buy condoms, early sexual debut and inappropriate forms of recreation). Individual factors (excessive use of alcohol, substance abuse, educational status, low self-esteem, and inability to resist sexual temptation, curiosity, and cell phone usage). Health service-related factors (cost of contraceptives, Inadequate and unskilled health workers, long waiting time and lack of privacy at clinics, lack of comprehensive sexuality education, misconceptions about contraceptives, and non-friendly adolescent reproductive services,) as influencing adolescent pregnancies in Sub-Saharan Africa CONCLUSION: High levels of adolescent pregnancies in Sub-Saharan Africa is attributable to multiple factors. Our study, however, categorized these factors into three major themes; sociocultural and economic, individual, and health service related factors as influencing adolescent pregnancies. Community sensitization, comprehensive sexuality education and ensuring girls enroll and stay in schools could reduce adolescent pregnancy rates. Also, provision of adolescent-friendly health services in schools and healthcare centers and initiating adolescent empowerment programs could have a positive impact.

Protocol for a cohort study of adolescent mental health service users with a nested cluster randomised controlled trial to assess the clinical and cost-effectiveness of managed transition in improving transitions from child to adult mental health services (the MILESTONE study).

INTRODUCTION: Disruption of care during transition from child and adolescent mental health services (CAMHS) to adult mental health services may adversely affect the health and well-being of service users. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Healthcare) study evaluates the longitudinal course and outcomes of adolescents approaching the transition boundary (TB) of their CAMHS and determines the effectiveness of the model of managed transition in improving outcomes, compared with usual care. METHODS AND ANALYSIS: This is a cohort study with a nested cluster randomised controlled trial. Recruited CAMHS have been randomised to provide either (1) managed transition using the Transition Readiness and Appropriateness Measure score summary as a decision aid, or (2) usual care for young people reaching the TB. Participants are young people within 1 year of reaching the TB of their CAMHS in eight European countries; one parent/carer and a CAMHS clinician for each recruited young person; and adult mental health clinician or other community-based care provider, if young person transitions. The primary outcome is Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) measuring health and social functioning at 15 months postintervention. The secondary outcomes include mental health, quality of life, transition experience and healthcare usage assessed at 9, 15 and 24 months postintervention. With a mean cluster size of 21, a total of 840 participants randomised in a 1:2 intervention to control are required, providing 89% power to detect a difference in HoNOSCA score of 0.30 SD. The addition of 210 recruits for the cohort study ensures sufficient power for studying predictors, resulting in 1050 participants and an approximate 1:3 randomisation. ETHICS AND DISSEMINATION: The study protocol was approved by the UK National Research Ethics Service (15/WM/0052) and equivalent ethics boards in participating countries. Results will be reported at conferences, in peer-reviewed publications and to all relevant stakeholder groups. TRIAL REGISTRATION NUMBER: ISRCTN83240263; NCT03013595 (pre-results).