Young female migrants and job placement brokers in Addis Ababa, Ethiopia.

Introduction: Rates of urbanization in Ethiopia are high and adolescent girls and young women are predominant among those who move from rural to urban areas. Young women frequently undertake rural-urban migration on their own or with a friend, and with little planning for their initial settlement in the city. They frequently rely on job placement brokers to place them into jobs upon arrival, with positions such as domestic work normally including accommodation. Methods: This is a qualitative study undertaken at the two largest bus stages in Addis Ababa, which are points of arrival for a large number of migrants from rural areas. Three categories of respondents were interviewed in-depth: migrant young women who had arrived within the last few days, job placement brokers who are located in and around the bus station, and market women/vendors at the bus stations who interact with both migrants and brokers. Results: Migrant girls' point of arrival was an inflection point of risk, especially among girls who were on their own, not accompanied or met at the bus terminal and lacking in plans or preparation of accommodation. Such girls were targeted by thieves at the bus station and by unscrupulous brokers, some of whom forced girls into sexual relations before placing them into paid work. In contrast, market women and some well-meaning brokers took steps to protect girls such as providing temporary accommodation. Conclusion: This research underscores the need for intensified support to rural-urban migrants to ensure safety and security at the time of arrival at their destination. This includes promotion of pre-migration education and planning; safety assets including sufficient money, cell phones and alternative contacts in the city; and arrangement for immediate, safe and secure accommodation. As a result of the study, a pilot program has been developed, using local resources to extend support for newly arriving migrant girls and young women.

Accidental traffickers: qualitative findings on labour recruitment in Ethiopia.

BACKGROUND: The growth of labour migration and associated risks of human trafficking and exploitation remain significant global human rights and health challenges. There is increasing policy interest in addressing structural determinants of adverse migration outcomes such as migrants' use of informal employment recruiters. In Ethiopia, "safe migration" policies have introduced regulations for registered private employment agencies and penalties for anyone else placing migrants into work overseas. Yet migrants continue to use informal facilitators who are often demonised as traffickers without evidence of their motivations, experiences or perceptions. We conducted qualitative interviews with 28 informal facilitators as part of a study into how recruitment practices shape risks for female migrants seeking domestic work in the Middle East and Gulf States. We present the realities of irregular recruitment on the ground, and how these practices are affected by policies that dichotomise recruiters into legal/safe and illegal/unsafe categories. RESULTS: We identified four main themes. First, arranging migration from rural areas differs from in the capital, Addis Ababa, where laws and regulations originate. Outside Addis Ababa, registration was difficult for facilitators to arrange, with little incentive to do so due to its lack of importance to prospective migrants. Second, the ability to circumvent legal requirements was considered an advantage of informal facilitators because it reduced costs and expedited migrants' departure. Third, facilitators did not work alone but operated in long "chains" of diverse actors. This meant migrants' safety was not determined by any given individual, but spread across numerous people involved in sending a migrant abroad, some of whom might be registered and others not. And finally, facilitators did not believe they could realistically safeguard migrants once they were outside of Ethiopia and working under different laws and employers. CONCLUSIONS: Findings from this study add to a growing body of work demonstrating the diversity of people involved in the migration process, and consequent oversimplification of popular policy solutions. A more effective approach might be to constructively engage informal facilitators and identify ways they could assist with referring migrant workers to registered agencies and safe employment, rather than criminalising their participation.

Factors associated with depression among young female migrants in Ethiopia.

BACKGROUND: Mental health disorders represent a significant share of disease burden for adolescents and young people and depression is among the leading causes of morbidity within this age group. With rural-urban migration increasing in many settings, and young females being among the main migrants, few studies have examined the impact of such major transitions on mental health. This paper measures levels of depression among young women who are rural-urban migrants in Ethiopia, as well as factors associated with depression. METHODS: This was part of a largescale study of urban migrant females aged 15-24 in Ethiopia, which took place in seven cities. Multiple categories of migrants were interviewed. We used modified PHQ-9 questions to measure depression and logistic regression models to examine its association with various characteristics including patterns of migration and violence. In all, 4,495 migrant females were interviewed. RESULTS: Twenty-one percent of migrant young women displayed symptoms of moderate or severe depression. Symptoms of depression were more common among commercial sex workers (37%) than among other categories of migrants. Factors significantly associated with depression were being in commercial sex work (OR 1.70), migrating before age 15 (OR 1.37), using a broker to find a job (OR 1.53), experiencing forced first sex (OR 2.16) and experiencing beating in the last three months (OR 2.16). CONCLUSION: This study reveals significant levels of depression among young women in Ethiopia who are rural-urban migrants. The study highlights the need to expand measurement of mental health conditions in health surveys and underscores the need for additional investments in mental health infrastructure, programs and services for marginalized groups in sub-Saharan Africa.

Migrant Women's Health and Safety: Why Do Ethiopian Women Choose Irregular Migration to the Middle East for Domestic Work?

BACKGROUND: Low-wage labour migration is an increasing determinant of global health, associated with risks of exploitation, abuse, and unsafe conditions. Despite efforts to prevent irregular migration and initiatives to warn individuals of the risks of trafficking, many migrants still opt for irregular channels, particularly women seeking jobs as domestic workers. Ethiopia is one of the largest source countries for female migrants entering the domestic labour market in the Middle East. This qualitative study explored migration decision making by Ethiopian women traveling to the Middle East for domestic labour, focusing on the use of irregular channels. METHODS: We conducted semistructured interviews with policy stakeholders, migration recruiters, and returnee domestic workers. RESULTS: We identified three main themes that help explain decision making by female migrants and their communities. First, women were not always clear whether they were using legally approved processes, particularly because of the range of individuals involved in arranging migration plans. Second, irregular migration was seen to be quicker and easier than regular migration procedures. Third, study participants believed the risks between irregular and regular migration were similar. CONCLUSION: Our study highlights challenges associated with antitrafficking initiatives that discourage irregular migration and suggests new perspectives to address the health risks linked to labour migration.

Changes in the prevalence of child marriage in Ethiopia, 2005-2016.

BACKGROUND: Child marriage has powerful implications for a young woman's reproductive health, education, and personal development as well as the development of communities and nations. Child marriage frequently marks the beginning of a young woman's sexual activity and early childbearing. As a country where child marriage is common, Ethiopia has placed additional emphasis on addressing child marriage over the past years. METHODS: Using data from Ethiopia Demographic and Health Surveys for 2005, 2011 and 2016, this paper explores trends in child marriage over the last decade in various locations and regions of Ethiopia. RESULTS: Between 2005 and 2016, the percentage of young Ethiopian women married before age 18 declined from 49 to 40%, a reduction of 18% from 2005 levels. The percentage of women married before age 15 experienced even greater reductions, declining by 26% in the same period. The greatest reductions in child marriage took place in the Addis Ababa, Amhara, and Tigray regions. Over the period, estimates for Oromia and Somali suggest that child marriage has increased in these regions. Notwithstanding recent declines, Afar, Beneshangul-Gumuz, Somali, and Oromia are regions where nearly half or more of all girls are married before age 18. CONCLUSIONS: Nationally, Ethiopia has experienced impressive declines in child marriage over the last decade. However, progress has also been uneven. Trends in the last decade have resulted in a geographical shift in where child marriage is most prevalent. In particular, locations that are challenging in terms of access, including the most remote and hard to reach, pose persistent challenges to those attempting to eradicate the practice. Intensifying efforts in rural areas and underserved regions can facilitate further declines in child marriage in Ethiopia.

Child marriage has powerful implications for young women's reproductive health, education, and welfare. Using data from Ethiopia Demographic and Health Surveys for 2005, 2011, and 2016, this paper analyzes subnational trends in child marriage over the last decade. Between 2005 and 2016, the percentage of Ethiopian women married before age 18 declined from 49 to 40%, a reduction of 18%. The percentage of women married before age 15 experienced even greater reductions, declining by 26% in the same period. The greatest reductions in child marriage took place in Addis Ababa, Amhara, and Tigray regions. Over the same period, estimates for Oromia and Somali regions suggest that child marriage has increased in these regions. Afar, Beneshangul-Gumuz, Somali, and Oromia are regions where more than or nearly half of all girls are married before age 18.Nationally, Ethiopia has experienced impressive declines in child marriage over the last decade. However, progress has also been uneven, resulting in a geographical shift in where child marriage is most prevalent. Remote and hard-to-reach locations pose persistent challenges to eradicating child marriage. Intensifying efforts in rural areas and underserved regions can achieve the elimination of child marriage in Ethiopia.

What Influences Girls' Age at Marriage in Burkina Faso and Tanzania? Exploring the Contribution of Individual, Household, and Community Level Factors.

PURPOSE: This comparative study explores the connections between potential drivers of child marriage among girls at the individual, household, and community levels. It provides insight into the multilevel influences on child marriage with the goal of informing policies and programs aimed at eliminating the practice. METHODS: We conducted a secondary analysis of baseline data from the Building Evidence to Delay Child Marriage Project, a large study undertaken in Burkina Faso and Tanzania. For each country, using data on adolescent girls and parents, we ran a series of nested logistic regression models to identify factors associated with having ever been married among girls aged 15-17 years. RESULTS: Findings indicate that child marriage among girls is shaped by a combination of factors at multiple levels and that the weight of influencing factors varies by context. At the household level, parental relationships were influential in both countries, although in different ways. The influence of the community varied considerably between countries, holding more importance in Burkina Faso than in Tanzania. In Burkina Faso, the importance of schooling and existence of alternative pathways for girls beyond marriage appears crucial to reducing child marriage. Other factors strongly associated with child marriage include girls' agency, the timing of girls' sexual initiation, and community norms, specifically views on child marriage among fathers. In Tanzania, early sexual initiation among girls was common and strongly associated with marriage during childhood; parents' fear of premarital sex and pregnancy also emerged as a significant factor.

Designing and Evaluating Scalable Child Marriage Prevention Programs in Burkina Faso and Tanzania: A Quasi-Experiment and Costing Study.

BACKGROUND: A significant number of girls are married as children, which negatively impacts their health, education, and development. Given the sheer numbers of girls at risk of child marriage globally, the challenge to eliminate the practice is daunting. Programs to prevent child marriage are typically small-scale and overlook the costs and scalability of the intervention. IMPLEMENTATION: This study tested and costed different approaches to preventing child marriage in rural Burkina Faso and Tanzania. The approaches tested were community dialogue, provision of school supplies, provision of a livestock asset, a model including all components, and a control arm. A quasi-experimental design was employed with surveys undertaken at baseline and after 2 years of intervention. We examined the prevalence of child marriage and school attendance controlling for background characteristics and stratified by age group. Programmatic costs were collected prospectively. RESULTS: Among those in the community dialogue arm in Burkina Faso, girls aged 15 to 17 years had two-thirds less risk (risk ratio [RR]=0.33; 95% confidence interval [CI]=0.19, 0.60) of being married and girls aged 12 to 14 years had a greater chance of being in school (RR=1.18; 95% CI=1.07,1.29) compared to the control site. In Tanzania, girls aged 12 to 14 years residing in the multicomponent arm had two-thirds less risk of being married (RR=0.33; 95% CI=0.11, 0.99), and girls 15 to 17 in the conditional asset location had half the risk (RR=0.52; 95% CI=0.30, 0.91). All the interventions tested in Tanzania were associated with increased risk of girls 12 to 14 years old being in school, and the educational promotion arm was also associated with a 30% increased risk of girls aged 15 to 17 years attending school (RR=1.3; 95% CI=1.01, 1.67). Costs per beneficiary ranged from US$9 to US$117. CONCLUSION: The study demonstrates that minimal, low-cost approaches can be effective in delaying child marriage and increasing school attendance. However, community dialogues need to be designed to ensure sufficient quality and intensity of messaging. Program managers should pay attention to the cost, quality, and coverage of interventions, especially considering that child marriage persists in the most hard-to-reach rural areas of many countries.

The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development.

Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.

Stigma as a barrier to family planning use among married youth in Ethiopia.

Nearly 33 million female youths have an unmet need for voluntary family planning (FP), meaning they are sexually active and do not want to become pregnant. In Ethiopia, age at marriage remains low: 40% and 14% of young women aged 20-24 were married by the ages of 18 and 15, respectively. Despite increases in FP use by married 15- to 24-year-olds from 5% in 2000 to 37% in 2016, unmet need remains high at 19%. Supply-and-demand factors have been shown to limit FP use, yet little is known about how stigma influences FP use among youth. This study validates an anticipated stigma (expectation of discrimination from others) index and explores its effect on unmet need. A cross-sectional survey was implemented with 15- to 24-year-old female youth in Ethiopia in 2016. The analytic sample included married respondents with a demand (met and unmet need) for FP (n=371). A five-item anticipated stigma index (Cronbach's α=0.66) was developed using principal component factor analysis. These items related to fear, worry and embarrassment when accessing FP. The findings showed that 30% agreed with at least one anticipated stigma question; 44% had an unmet need; 58% were married before age 18; and 100% could name an FP method and knew where to obtain FP. In multivariate regression models, youth who experienced anticipated stigma were significantly more likely to have an unmet need, and those who lived close to a youth-friendly service (YFS) site were significantly less likely to have an unmet need. Interventions should address anticipated stigma while focusing on social norms that restrict married youth from accessing FP; unmet need may be mitigated in the presence of a YFS; and the anticipated stigma index appears valid and reliable but should be tested in other countries and among different adolescent groups.

Condom use at last sex by young men in Ethiopia: the effect of descriptive and injunctive norms.

BACKGROUND: Condoms are an important prevention method in the transmission of HIV and sexually transmitted infections as well as unintended pregnancy. Individual-level factors associated with condom use include family support and connection, strong relationships with teachers and other students, discussions about sexuality with friends and peers, higher perceived economic status, and higher levels of education. Little, however, is known about the influence of social norms on condom use among young men in Ethiopia. This study examines the effect of descriptive and injunctive norms on condoms use at last sex using the theory of normative social behavior. METHODS: A cross-sectional survey was implemented with 15-24 year old male youth in five Ethiopian regions in 2016. The analytic sample was limited to sexually active single young men (n = 260). Descriptive statistics, bivariate and multivariate logistic regressions were conducted. An interaction term was included in the multivariate model to assess whether injunctive norms moderate the relationship between descriptive norms and condom use. RESULTS: The descriptive norm of knowing a friend who had ever used condoms significantly increased respondents' likelihood of using condoms at last sex. The injunctive norm of being worried about what people would think if they learned that the respondent needed condoms significantly decreased their likelihood to use condoms. The injunctive norm did not moderate the relationship between descriptive norms and condom use. Young men who lived closer to a youth friendly service (YFS) site were significantly more likely to have used condoms at last sex compared to those who lived further away from a YFS site. CONCLUSIONS: Social norms play an important role in decision-making to use condoms among single young men in Ethiopia. The interplay between injunctive and descriptive norms is less straightforward and likely varies by individual. Interventions need to focus on shifting community-level norms to be more accepting of sexually active, single young men's use of condoms and need to be a part of a larger effort to delay sexual debut, decrease sexual violence, and increase gender equity in relationships.

Married Adolescents and Family Planning in Rural Ethiopia: Understanding Barriers and Opportunities.

Large numbers of girls in the developing world are married before age 18, an estimated 100 million girls in the next decade. It is assumed that newly married girls are under pressure to have children early in marriage. However, there is increasing evidence that married adolescent girls have significant levels of unmet need for family planning (FP). This qualitative study explores married girls' knowledge and demand for FP, as well as barriers and support. Qualitative data was obtained from girls who married as children in rural Ethiopia. Respondents demonstrated a high interest in FP, while the power dynamics within arranged marriages were the biggest factor influencing FP use. Disapproval of FP use was considerable among in-laws and community members; however, partner approval was the main determining factor in girls' FP use. Some service providers reportedly reinforced this dynamic; some girls reported that they requested confirmation of the husbands' approval of FP use. The findings suggest further investment in addressing social norms related to girls' status and voice.

Evaluation of a reproductive health program to support married adolescent girls in rural Ethiopia.

Few reproductive health programs are targeted to married adolescent girls. This study measures changes associated with a program for married adolescent girls and a parallel husbands' program, in rural Ethiopia. The married girls' program provided information on communication, self-esteem, reproductive health and gender through girls' groups. The husbands' program focused on non-violence, support to families, and reproductive health. Population-based surveys were undertaken among married girls, at midterm and end line. Outcomes of interest were husbands' assistance with domestic work, accompaniment to the clinic, family planning use, voluntary counseling and testing (VCT), and domestic violence. Overall, 1,010 married girls were interviewed. Participation in the girls' groups was associated with improvements in help with domestic work, accompaniment to the clinic, family planning and VCT. Further improvements were recorded when both partners participated. For example, participating girls were nearly 8 times more likely to receive VCT (OR 7.7) than nonparticipants, and more than 18 times more likely if both partners participated (OR 18.3). While these results are promising, there were indications of selectivity bias that could have contributed to the positive results. Programs engaging both wives and husbands can result in incremental improvements to the health and well-being of girls married early.

Evaluation of a reproductive health program to support married adolescent girls in rural Ethiopia

Few reproductive health programs are targeted to married adolescent girls. This study measures changes associated with a program for married adolescent girls and a parallel husbands' program, in rural Ethiopia. The married girls' program provided information on communication, self-esteem, reproductive health and gender through girls' groups. The husbands' program focused on non-violence, support to families, and reproductive health. Population-based surveys were undertaken among married girls, at midterm and end line. Outcomes of interest were husbands' assistance with domestic work, accompaniment to the clinic, family planning use, voluntary counseling and testing (VCT), and domestic violence. Overall, 1,010 married girls were interviewed. Participation in the girls' groups was associated with improvements in help with domestic work, accompaniment to the clinic, family planning and VCT. Further improvements were recorded when both partners participated. For example, participating girls were nearly 8 times more likely to receive VCT (OR 7.7) than nonparticipants, and more than 18 times more likely if both partners participated (OR 18.3). While these results are promising, there were indications of selectivity bias that could have contributed to the positive results. Programs engaging both wives and husbands can result in incremental improvements to the health and well-being of girls married early. Afr J Reprod Health 2014; 18[2]: 68-76)

Early marriage, marital relations and intimate partner violence in Ethiopia.

CONTEXT: A considerable proportion of women worldwide are married during childhood. Although many studies have examined early marriage (before age 18), few have compared outcomes or correlates among girls married during different stages of adolescence or have focused on girls married very early (before age 15). METHODS: Data from a population-based survey conducted in 2009-2010 in seven Ethiopian regions were used to examine early marriage among 1,671 women aged 20-24. Cross-tabulations and logistic regression were used to compare characteristics and contextual factors among girls married before age 15, at ages 15-17 or at ages 18-19 and to identify factors associated with selected marital outcomes. RESULTS: Seventeen percent of respondents had married before age 15 and 30% had married at ages 15-17. Most of those who married before age 18 had never been to school. Compared with young women who had married at ages 18-19, those married before age 15 were less likely to have known about the marriage beforehand (odds ratio, 0.2) and more likely to have experienced forced first marital sex (3.8). Educational attainment was positively associated with foreknowledge and wantedness of marriage and with high levels of marital discussions about fertility and reproductive health issues. CONCLUSIONS: Initiatives addressing the earliest child marriages should focus on girls who have left or never attended school. Given the vulnerability of girls married before age 15, programs should pay special attention to delaying very early marriages.

Evaluation of Berhane Hewan: a program to delay child marriage in rural Ethiopia.

CONTEXT: Early marriage limits girls' opportunities and compromises their health, yet in Sub-Saharan Africa many girls are married before the age of 18, and few programs have sought to increase the age at marriage on the continent. METHODS: Berhane Hewan was a two-year pilot project conducted in 2004-2006 that aimed to reduce the prevalence of child marriage in rural Ethiopia, through a combination of group formation, support for girls to remain in school and community awareness. A quasi-experimental research design with baseline and endline surveys was used to measure changes in social and educational participation, marriage age, reproductive health knowledge and contraceptive use. Chi-square tests, proportional hazards models and logistic regressions were conducted to assess changes associated with the project. RESULTS: The intervention was associated with considerable improvements in girls' school enrollment, age at marriage, reproductive health knowledge and contraceptive use. Particularly among girls aged 10-14, those exposed to the program were more likely than those in the control area to be in school at the endline survey (odds ratio, 3.0) and were less likely to have ever been married (0.1). However, among girls aged 15-19, those in the intervention area had an elevated likelihood of having gotten married by the endline (2.4). Sexually experienced girls exposed to the intervention had elevated odds at endline of having ever used contraceptives (2.9). CONCLUSIONS: The success of the Berhane Hewan program, one of the first rigorously evaluated interventions to delay marriage in Sub-Saharan Africa, suggests that well-designed and effectively implemented programs can delay the earliest marriages until later adolescence.

Social exclusion and early or unwanted sexual initiation among poor urban females in Ethiopia.

CONTEXT: Numerous studies of adolescent sexual behavior have explored factors associated with early sexual debut. However, few studies have examined the role of social exclusion and marginalization in relation to early and unwanted sexual initiation. METHODS: A population-based study of 1,837 out-of-school females aged 10-19 was conducted in three low-income urban areas of Ethiopia in 2008. Descriptive and multivariate analyses were used to identify characteristics associated with having experienced coerced sexual initiation and sexual debut before age 15. RESULTS: Nearly half (48%) of the young women in the sample were domestic workers, and many reported significant social exclusion, including lack of friends, community support networks and group membership. Overall, 23% reported being sexually experienced and 27% of those had first had sex before age 15. Compared with other young women, domestic workers were significantly more likely to have had sex before age 15 (odds ratio, 3.3), and to have been coerced into having sex (1.8). Social exclusion was associated with significantly higher odds of coerced first sex (2.0). CONCLUSIONS: Programs for female adolescents should build their social capital and inclusion, as well as provide opportunities for them to stay in school and obtain positive and nonexploitive forms of work.

Differential use of adolescent reproductive health programs in Addis Ababa, Ethiopia.

PURPOSE: Adolescent reproductive health programs in Africa have largely remained as small-scale pilot programs, however, there is increasing interest in bringing programs to scale. Evaluations have focused on individual programs and few have gathered population-based information on the reach of program models and the profile of adolescents who utilize services, versus those who do not. This study examines the coverage and utilization of existing adolescent programs in Addis Ababa, Ethiopia. METHODS: Population-based surveys were undertaken among over 1000 adolescents aged 10 to 19 years in slum areas of Addis Ababa, Ethiopia. An inventory of youth programs including youth centers and peer education programs was compiled in the study area. RESULTS: Eight peer education programs and six youth centers were operating in the study area. Twenty percent of boys and only 7% of girls had visited a youth center in the last year; 27% of boys and 15% of girls had had contact with a peer educator. Older adolescents, especially boys, were more likely to utilize programs. Girls who work long hours and who are isolated are less likely to access and benefit from programs. CONCLUSIONS: Greater segmentation of the adolescent population is needed in the design and content of adolescent reproductive health programs. In addition, programmers should pay attention to the specific circumstances of young people in local settings, particularly vulnerable, hard-to-reach sub-groups of adolescents, including girls.

What is youth-friendly? Adolescents' preferences for reproductive health services in Kenya and Zimbabwe.

While there has been increased attention to youth-friendly reproductive health services, little research has been conducted among adolescents in developing countries to assess what characteristics of reproductive health services are most important to them. Large scale population-based surveys were carried out among youth in Kenya and Zimbabwe. A list of characteristics that programmers often think of as youth-friendly was read to respondents, after which they were asked to assess the importance of those characteristics in choosing their reproductive health services. Adolescents rated confidentiality, short waiting time, low cost and friendly staff as the most important characteristics. The least important characteristics included youth-only service, youth involvement and young staff, suggesting that adolescents do not prioritise stand-alone youth services such as youth centres, or necessarily need arrangements particular to youth such as youth involvement. The findings imply that most existing clinical services, even in the most resource-poor settings, are in a position to improve their level of youth friendliness.