Evaluation of mainstreaming youth-friendly health in private clinics in Malawi

Background: High fertility rates and low modern contraceptive use put African youth and adolescents at high risk for health complications, including maternal mortality. Mainstreaming youth-friendly health services (YFHS) into existing services is one approach to improve access to reproductive health services for youth and adolescents. The objective of the evaluation was to assess the effects of a Population Services International (PSI)-sponsored YFHS training package on voluntary uptake of family planning among youth and perceptions of service quality by youth and trained healthcare providers in Malawi. Methods: In 2018, a mixed-methods convergent parallel design was used to assess relevant monitoring and evaluation documents and service statistics from PSI Malawi and qualitative data on perceptions of service quality from Malawian youth and healthcare providers. The data were assessed through separate descriptive and thematic analysis and integrated to generate conclusions. Results: Results show that the number of family planning clients ages 15-24 increased from 72 to 2278 per quarter during the implementation of the YFHS training packages, however, positive trends in client numbers were not sustained after youth outreach activities ended. Focus group discussions with 70 youth and adolescents indicated that clinics were perceived as providing high-quality services to youth. The main barriers to accessing the services were cost and embarrassment. Interviews with ten healthcare providers indicated that many made efforts to improve clinic accessibility and understood the barrier of cost and importance of outreach to youth and the broader community. Conclusions: The findings support research showing positive effects of mainstreaming YFHS when training for healthcare staff is combined with additional YFHS programming components. Furthermore, the findings provide evidence that provider training alone, though beneficial to perceived service quality, is not sufficient to sustain increases in the number of adolescent and youth family planning clients. The evaluation used a mixed-methods convergent parallel design. The quantitative phase was a non-experimental, retrospective design which included desk review of information from relevant monitoring and evaluation documents triangulated with service statistics collected through PSI’s health information system. The qualitative phase incorporated data collected from focus groups and key informant interviews. Each phase was analyzed separately, and findings were integrated to generate conclusions and suggestions to improve and sustain quality YFHS. Research and data collection were led by the United States Agency for International Development-funded MEASURE Evaluation project at the Carolina Population Center, University of North Carolina at Chapel Hill. The data used for the evaluation are summarized below. Materials related to PSI activities to support the mainstreaming of YFHS in Malawi were collected and reviewed between June–October 2018. The documents included strategic documents, program reports and technical materials, such as technical briefs, supportive supervision checklists, and the YFHS training curriculum, facilitator’s guide and training workshop materials. Information requests were sent to points of contact at PSI Malawi and PSI Washington to clarify emergent questions. The data available for the evaluation included monthly service data from January 2013–July 2018 from clinics in which at least one provider received YFHS training in 2013, 2014, 2016, or 2017. The data included number of services by age group (15–19 and 20–24) and FP method related to service (IUD, implant, oral contraceptive pill, injectable, condoms, or counseling only). Nine focus group discussions (FGD) were conducted, three with males ages 18–25 and six with females (two for ages 15–19 and four for ages 20–24) living in communities served by Tunza Family Health Network clinics that had worked to mainstream YFHS. The FGDs took place in the towns of Dowa, Kasungu, Mzuzu, Ekwendeni, Lilongwe, Nkhata Bay, and Nkhotakota in the central and northern regions of Malawi. Groups ranged in size from 4 to 13 youths—the group of four was a result of heavy rains that kept some recruited individuals from attending the discussion session. Following a convenience sampling approach, local organizations were contacted to assist with recruiting and finding space for the FGDs. Recruitment and discussions took place near the health facility or in program space in the selected community. Inclusion criteria for participants in FGDs (1) were youth ages 15–24, regardless of parity or marital status, and (2) had knowledge of the PSI network member healthcare facility, regardless of whether they had personally been a client. There were no exclusions based on gender, marital status, race, or ethnicity. Focus group participants were asked about their attitudes toward services offered to youth, perceptions of service quality at the facility, and whether the healthcare facility was seen as meeting the needs of youth in their communities. Focus group discussions lasted approximately 1 hour. Key informant interviews were conducted with ten healthcare providers and staff that received the YFHS training since 2014. The sample allowed for about one-quarter of the overall number of trained health staff to provide input to the study. The ten healthcare providers, one per clinic, were purposively sampled among Tunza clinics to include different geographic locations and length of time since receiving the training. Staff eligible for interview were those who (1) received the training and materials for mainstreaming YFHS in the past 5 years, (2) were currently working in Tunza YFHS clinics, and (3) were available for the interview on the day of data collection. Staff eligible for the interviews were identified by the research team utilizing a list of all eligible clinics. An attempt was made to include a mix of service provider types (in-charges, physicians, counselors, and nurses). Service providers were not excluded by whether they currently serve adolescents and youth. Initial contact with selected staff was made by telephone; all who were contacted agreed to be interviewed. The communities in which the health staff interviews took place included Dowa, Kasungu, Mzuzu, Lilongwe, Nkhata Bay, and Nkhotakota. Healthcare providers were interviewed in a private space in their clinic and were asked about their attitudes on mainstreaming YFHS; their perceptions of successes and challenges to these efforts; attitudes on YFHS training; and perceptions on sustainability of the YFHS efforts. The interviews were structured around the WHO Quality of Care Framework standards for YFHS and the WHO Quality Assessment Guidebook for assessing health services for youth [20, 32]. Themes included access, acceptability, confidentiality, equity, and effectiveness [20]. Providers were also asked their opinions for improving YFHS efforts and areas for future work. Interviews lasted approximately thirty minutes. The qualitative data were collected from November 25 to December 5, 2018, by Dr. Thakwalakwa (PhD) and Mr. Alfonso (MA), both with extensive experience in conducting key informant interviews and FGDs and fluent speakers of languages used in data collection. The FGDs were conducted in Chichewa. The key informant interviews were conducted in English. Interviewer guides included prompts when necessary and were reviewed by technical advisors at PSI. The FGDs and interviews were audio recorded, transcribed, and translated into English as needed. Evaluation of PSI Malawi’s YFHS training and intervention package included a document review and identification and contextualization of information contained within program reports and strategy documents. Service statistics were provided in Excel. Descriptive statistics were then used to assess trends in FP services to youth. Graphs were developed to display trends. Client numbers were assessed by quarter, in an effort to smooth out data issues, such as the effects of reporting gaps for any single month. Content analysis of qualitative data according to themes used in the interview and focus group guides was undertaken to assess youth’s perception of service quality and healthcare staff’s perceptions of the YFHS training and implementation in Malawi. The analysis of qualitative data involved three iterative steps: reading, organizing and displaying, and reducing. First, a member of the study team read each transcript at least twice and highlighted sections of the transcripts to help bookmark quotes that were potentially meaningful or unexpected. Next, to organize and display the data, a matrix was developed in Excel to summarize typical and atypical responses to interview questions. The final step involved summarizing the findings and analyzing by respondent sex and age to identify relevant themes and patterns of responses. The final step was iterative and involved the entire research team. Information from documents, key informant interviews, and FGDs was used to contextualize the available service data and to identify and assess the strengths of implementation of a context-specific, multipronged intervention that paired YFHS provider and staff training with community outreach and demand-generation strategies. The analysis also identified barriers to effectiveness of YFHS provider and staff training, long-term perceptions of the YFHS training, and youth perceptions of barriers to accessing FP within the Malawian context and assessed whether the training was successful in increasing use of FP services among youth. In preparation for the activity, a memorandum of understanding for the sharing of data between PSI and MEASURE Evaluation was signed on November 10, 2017. The University of North Carolina Institutional Review Board approved the evaluation protocol and data collection tools, including consent forms, on August 24, 2018, through expedited review #18–1303. The Malawi National Committee on Research in the Social Sciences and Humanities approved the collection of qualitative data on November 12, 2018, through permit #P.09/18/318. Informed written consent and assent was obtained from all key informants and FGD participants. Providers and staff approached for participation in the study were informed that the interview was not required by Tunza nor would it influence their relationship or affiliation with PSI. A waiver of parental permission was received for participants aged 15–17, in accordance to section 4.1.2 of the Malawian National Commission for Science and Technology research framework, which states that parental permission may be waived for research involving adolescents about contraceptive access [33]. The anticipated risks of participating in FGDs included possible disclosure of personal information and the potential for feeling uncomfortable discussing RH topics. To reduce these risks, researchers emphasized that participants should not disclose personal information about their sexual behaviors, that what was discussed in the group should be kept confidential, and that participation in the discussion was voluntary and participants were free to refuse to answer any question or to leave at any time.