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

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Study Justification:
– High fertility rates and low modern contraceptive use in African youth and adolescents put them at high risk for health complications, including maternal mortality.
– Mainstreaming youth-friendly health services (YFHS) into existing services is a potential approach to improve access to reproductive health services for youth and adolescents.
– The evaluation aimed to assess the effects of a YFHS training package on voluntary uptake of family planning among youth and perceptions of service quality by youth and healthcare providers in Malawi.
Highlights:
– The number of family planning clients ages 15-24 increased significantly during the implementation of the YFHS training packages.
– Focus group discussions with youth indicated that clinics were perceived as providing high-quality services to youth.
– Barriers to accessing the services included cost and embarrassment.
– Healthcare providers made efforts to improve clinic accessibility and understood the importance of outreach to youth and the broader community.
Recommendations:
– Combine YFHS training for healthcare staff with additional YFHS programming components to sustain increases in the number of adolescent and youth family planning clients.
– Address the barriers of cost and embarrassment to improve access to youth-friendly health services.
– Continue efforts to improve clinic accessibility and outreach to youth and the broader community.
Key Role Players:
– Population Services International (PSI) Malawi
– United States Agency for International Development (USAID)
– MEASURE Evaluation project at the Carolina Population Center, University of North Carolina at Chapel Hill
– Tunza Family Health Network clinics
– Malawian youth and adolescents
– Trained healthcare providers
Cost Items for Planning Recommendations:
– YFHS training materials and curriculum development
– Outreach activities and community engagement
– Clinic accessibility improvements
– Staff training and capacity building
– Monitoring and evaluation activities
– Research and data collection expenses
– Communication and awareness campaigns

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it includes a mixed-methods convergent parallel design, which allows for both quantitative and qualitative data to be collected and analyzed. The evaluation used a variety of data sources, including monitoring and evaluation documents, service statistics, focus group discussions, and key informant interviews. The findings are supported by the data collected and provide insights into the effects of the youth-friendly health services training package on family planning uptake and service quality perceptions. To improve the evidence, it would be beneficial to include more details on the sampling methods used for the focus group discussions and key informant interviews, as well as the specific analysis techniques employed for the qualitative data.

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.

Based on the information provided, here are some potential innovations that can be used to improve access to maternal health:

1. Youth-friendly health services (YFHS): Mainstreaming YFHS into existing services can help improve access to reproductive health services for youth and adolescents. This approach involves training healthcare providers to offer services that are tailored to the needs and preferences of young people.

2. Outreach activities: Conducting outreach activities specifically targeted at youth and adolescents can help raise awareness about maternal health services and encourage them to seek care. These activities can include community events, school-based programs, and peer education initiatives.

3. Cost reduction strategies: Addressing the barrier of cost can improve access to maternal health services. This can be done through subsidies or financial assistance programs that make services more affordable for young people.

4. Addressing embarrassment: Embarrassment can be a significant barrier to accessing maternal health services for youth and adolescents. Implementing strategies to create a more comfortable and non-judgmental environment in healthcare facilities can help overcome this barrier.

5. Provider training: Training healthcare providers on youth-friendly approaches and effective communication techniques can improve the quality of care provided to young people. This includes ensuring that providers have the knowledge and skills to address the unique needs and concerns of youth and adolescents.

6. Sustainability planning: To sustain the positive effects of mainstreaming YFHS, it is important to develop long-term sustainability plans. This can involve ongoing training and support for healthcare providers, as well as continued outreach and awareness campaigns targeted at youth and the broader community.

It is important to note that these recommendations are based on the specific evaluation mentioned in the provided information. The effectiveness of these innovations may vary depending on the context and specific needs of different populations.
AI Innovations Description
The evaluation described in the provided text focused on the effects of mainstreaming youth-friendly health services (YFHS) in private clinics in Malawi. The objective was to assess the impact of a YFHS training package on the uptake of family planning among youth and the perceptions of service quality by both youth and healthcare providers.

The evaluation utilized a mixed-methods convergent parallel design, which involved both quantitative and qualitative data collection and analysis. The quantitative phase involved a retrospective analysis of monitoring and evaluation documents and service statistics from PSI Malawi. The qualitative phase included focus group discussions with youth and adolescents, as well as key informant interviews with healthcare providers.

The findings of the evaluation showed that the number of family planning clients aged 15-24 increased significantly during the implementation of the YFHS training packages. However, these positive trends were not sustained after youth outreach activities ended. Focus group discussions with youth indicated that clinics were perceived as providing high-quality services, but barriers to accessing the services included cost and embarrassment. Interviews with healthcare providers revealed that they made efforts to improve clinic accessibility and understood the importance of outreach to youth and the broader community.

Based on the findings, the evaluation recommended that the positive effects of mainstreaming YFHS can be sustained when training for healthcare staff is combined with additional YFHS programming components. It also highlighted the need to address barriers such as cost and embarrassment to improve access to maternal health services for youth and adolescents.

Overall, the evaluation provided valuable insights into the effectiveness of mainstreaming YFHS in improving access to maternal health services in Malawi and offered recommendations for further improvement and sustainability of these efforts.
AI Innovations Methodology
The evaluation described in the provided text aimed to assess the effects of a Population Services International (PSI)-sponsored youth-friendly health services (YFHS) training package on improving access to reproductive health services for youth and adolescents in Malawi. The evaluation utilized a mixed-methods convergent parallel design, which involved both quantitative and qualitative data collection and analysis.

The quantitative phase of the evaluation involved a non-experimental, retrospective design. It included a desk review of relevant monitoring and evaluation documents and service statistics collected through PSI’s health information system. The data collected included monthly service data from January 2013 to July 2018, specifically focusing on clinics where at least one provider received YFHS training in 2013, 2014, 2016, or 2017. The data analyzed included the number of family planning clients aged 15-24 and the types of family planning methods utilized.

The qualitative phase of the evaluation included focus group discussions (FGDs) and key informant interviews. Nine FGDs were conducted with male and female youth aged 15-24 living in communities served by Tunza Family Health Network clinics that had implemented YFHS. The FGDs explored attitudes toward services offered to youth, perceptions of service quality, and whether the healthcare facilities met the needs of youth in their communities. Ten key informant interviews were conducted with healthcare providers and staff who had received YFHS training. The interviews explored attitudes toward mainstreaming YFHS, perceptions of successes and challenges, and opinions on improving YFHS efforts.

The data collected from both the quantitative and qualitative phases were analyzed separately. Descriptive statistics were used to assess trends in family planning services to youth, and graphs were developed to display these trends. Content analysis was conducted on the qualitative data to identify themes and patterns of responses. The findings from both phases were then integrated to generate conclusions and suggestions for improving and sustaining quality YFHS.

The evaluation was conducted 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 collection took place between November 25 and December 5, 2018, and was led by experienced researchers. Informed written consent and assent were obtained from all participants, and ethical approval was obtained from relevant review boards.

Overall, the evaluation methodology involved a comprehensive assessment of both quantitative and qualitative data to evaluate the impact of the YFHS training package on improving access to reproductive health services for youth and adolescents in Malawi. The findings provided insights into the effectiveness of the training and identified barriers and areas for improvement in order to sustain and enhance the quality of YFHS.

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