Abstract
BackgroundWhile there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. In order to have a significant, long-term impact, these initiatives must be implemented over a sustained period and on a large scale. We conducted a process evaluation of the 10-fold scale up of an evaluated youth-friendly services intervention in Mwanza Region, Tanzania, in order to identify key facilitating and inhibitory factors from both user and provider perspectives.MethodsThe intervention was scaled up in two training rounds lasting six and 10 months. This process was evaluated through the triangulation of multiple methods: (i) a simulated patient study; (ii) focus group discussions and semi-structured interviews with health workers and trainers; (iii) training observations; and (iv) pre- and post-training questionnaires. These methods were used to compare pre- and post-intervention groups and assess differences between the two training rounds.ResultsBetween 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time, trainers' confidence and ability to lead sessions improved. The district-led training significantly improved knowledge relating to HIV/AIDS and puberty (RR ranged from 1.06 to 2.0), attitudes towards condoms, confidentiality and young people's right to treatment (RR range: 1.23-1.36). Intervention health units scored higher in the family planning and condom request simulated patient scenarios, but lower in the sexually transmitted infection scenario than the control health units. The scale up faced challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints.ConclusionsYouth-friendly services interventions can remain well delivered, even after expansion through existing systems. The scaling-up process did affect some aspects of intervention quality, and our research supports others in emphasizing the need to train more staff (both clinical and non-clinical) per facility in order to ensure youth-friendly services delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale up.
Highlights
IntroductionIntroduction ofManual 2: 12-day training of 24 DTs with Ministry of Health and Social Welfare (MoHSW) manualOct 2006 to July 2007 Training with Manual 2: Eight training sessions of 221 HWs (12-day training)Training evaluation - 16 days observation of five training sessions - 208 pre- & 203 post-training questionnaires - Informal interviewsBaseline study†: Interviews with 20 HWs prior to receiving the training in 2006Simulated patient study: One simulated patient (SP) visits to 15 health units: eight with trained HWs (intervention) & seven without trained HWs (control)Health worker interviews: Follow-up interviews with 30 HWs from the same health units visited by the SPTraining evaluation - 20 days observation of three - training sessions - 221 pre- & post-training questionnairesFollow-up study: Interviews with 15 MkV-trained HWs, two group discussions & two interviews with non-MkV-trained HWsKey: † The intervention had already begun prior to the research team being in place
Questionnaires were available from 208 (100%) and 203 (98%) health workers trained in Round 1, and from 221 (100%) and 221 (100%) health workers trained in Round 2
The number of health workers selected for training varied by type of health unit, and represented, on average, 50% of clinical staff
Summary
Introduction ofManual 2: 12-day training of 24 DTs with MoHSW manualOct 2006 to July 2007 Training with Manual 2: Eight training sessions of 221 HWs (12-day training)Training evaluation - 16 days observation of five training sessions - 208 pre- & 203 post-training questionnaires - Informal interviewsBaseline study†: Interviews with 20 HWs prior to receiving the training in 2006Simulated patient study: One SP visits to 15 health units: eight with trained HWs (intervention) & seven without trained HWs (control)Health worker interviews: Follow-up interviews with 30 HWs from the same health units visited by the SPTraining evaluation - 20 days observation of three - training sessions - 221 pre- & post-training questionnairesFollow-up study: Interviews with 15 MkV-trained HWs, two group discussions & two interviews with non-MkV-trained HWsKey: † The intervention had already begun prior to the research team being in place. While there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. There is increasing recognition of the need to break down the barriers that prevent young people from accessing quality health care [1,2,3,4,5] This is especially so for sexually transmitted infection (STI) and reproductive health services in sub-Saharan Africa, which are . The National Adolescent Friendly Clinic Initiative in South Africa is one of the few YFS programmes that has been scaled up and evaluated It was implemented nationally by building the capacity of health workers and establishing national standards and criteria for adolescent health care in public clinics across South Africa [17]. There was limited in-depth analysis of the implementers’ and young people’s point of view
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