Examining functional sexual and reproductive health and right-based friendly services: perspectives from exit adolescents, caregivers, and health workers at health services delivery points in Tanzania

Abstract

Background

The lack of adequate access to and use of sexual and reproductive health care by youth and adolescent, n low- and middle-income countries persists despite international accords on their rights, which exposes them to violence against children; early and unintended pregnancies; and sexually transmitted infections. This study examined functional sexual and reproductive health and right-based friendly services as perceived by exit male and female adolescents, caregivers, and health workers at the Tanzanian health services delivery points as they were the ones who would share their opinions to establish a diversified and representative reality about the matter based on sex.

Methods

This was a multicentric study among 205 randomly selected participants in eleven selected health facilities within the three regions of Tanzania including Dar es Salaam, Dodoma, and Kigoma regions using a one-time descriptive cross-sectional design with a quantitative research approach from 01 to 30 November 2022. Triangulation technique of data collection activities using structured questionnaires and observation checklist adopted from the Tanzanian Ministry of Health was used to collect data. IBM Statistical Package for Social Sciences version 26 data entry templates (Sa PSS – 26) were used to analyze data descriptively to establish frequencies and percentages.

Results

Results indicated that 205 participants were assessed in this study with a response rate of 100%. Exit adolescents (46%); health workers in dispensaries (60%), and community members (42%) were more likely to confirm the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points. The SRH displays (50%); adolescent rights (6%) and confidentiality (5%) were the least reported functional SRH aspects by the study participants. It was noted that the 11 health services delivery points in their totality did not fully implement the National standards in providing the services to adolescents and youth of which standards III (54.0%) and VIII (46.1%) scored the lowest.

Conclusion

The results of this study have uncovered that there is disperities in the availability and accessibility of functional SRH right-based adolescent and youth-friendly services across the levels of health facilities; among adolescents and community members. Hospitals were more likely to confirm the availability of Functional Right Based Youth Friendly Services than at health centers and dispensaries with female adolescents, youth, and community members being disadvantaged. There is a need to address issues of differentials in equity to the accessibility of services among adolescents, youth, and community members by improving functional sexual and reproductive health and right-based friendly services provision infrastructures, health care workers capacity building, and mechanisms or approaches to increase adolescents’ access and uptake to SRHR services.

Introduction

Adolescence is the phase of life between childhood and adulthood, and it is a unique stage of human development and an important time for laying the foundations of good health [1, 2]. The World Health Organization (WHO) defines adolescents as those between 10 and 19 years of age [3]. Other overlapping terms used are the youth defined by the United Nations as persons aged 15–24 years, and young people as persons aged 10–24 years, which combine adolescents and youth [4]. The existing body of knowledge indicates that the great majority of adolescents are included in the age-based definition of “child” as adopted by the Convention on the Rights of the Child [5]. WHO [6] estimates that, of the 7.2 billion world population, 42% (over 3 billion) are younger than 25 years, 18% (1.2 billion) are adolescents aged 10 to 19 years. About 88% of adolescents live in developing countries whereby Sub-Saharan Africa (SSA) constitutes 18% of them. It is also projected that by 2010 to 2030 the adolescent population in Sub-Saharan Africa will increase to 1.3 billion [7].

Various reports and literatures [8–12] have highlited that to grow and develop in good health, adolescents need information, including age-appropriate comprehensive sexuality education; opportunities to develop life skills; health services that are acceptable, equitable, appropriate, and effective; and safe and supportive environments. Nevertheless, be ealth Organization (WHO) recognizes that adolescent-friendly sexual and reproductive health (SRH) education; rights and services delivered in a holistic approach, have the potentials of empowering adolescents cognitively and with life skills for positive behavioral change [13]. However, authors [14–16] have possed that SRH education; rights and services need to be responsive; and comfortable; and offer a favorable environment and atmosphere that attracts adolescents. Moreover, it has been reported by various scholars [17, 18] that such SRH education; rights and services need to be sex-sensitive; demonstrate mutual respect; patience; and non-judgemental attitudes; accessible; affordable; acceptable; and available to adolescents and provided by competent personnel.

Investiments on the comprehensive friendly SRH education; rights and education have been launched and openly run in developed nations than in developing ones including Sub-Saharan African countries [19–23]. Based on these barriers that restrict adolescents and youth to access high-quality SRH services, a growing recognition of the need to make existing health services adolescent and youth-friendly seem to emerge [20]. To facilitate the making of existing health services youth-friendly, the nations around the globe, Tanzania inclusive has developed the National Standards and Implementation Guide for Quality Health Care Services for Adolescents [24, 25]. This document provides a standards-driven approach to improving the quality of healthcare services for adolescents and minimize variability and ensure a minimal required level of quality to protect adolescents’ rights in healthcare.

Nevertheless, the government of Tanzania as one among the developing nations has kept responding to the Sustainable Development Goals (SDGs) particularly number three is implementing the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030 which supports the 2030 Agenda for Sustainable Development and WHO Global Accelerated Action for the Health of Adolescents (AA-HA! ) 2017; as well as the WHO Operational Framework on Sexual Health and its Linkages to Reproductive Health [25]. Nevrtheless, the government of Tanzania implements the National Health Policy (2007), which targets to decrease morbidity and mortality by improving quality health care that addresses the needs of special groups, especially pregnant women, neonates, infants, and children under five years of age, and to ensure survival, thriving, and flourishing of women, children, and adolescents [26, 27].

Additionally, the country is implementing the Health Sector Strategic Plan number five (2021/2022–2025/2026) to further address the agenda for adolescents’ health and well-being while One Plan III (2021/2022–2025/2026) for people-centered health services, including adolescents; more specifically on improving the availability and access to sexual and reproductive health services for young people to reduce teenage pregnancy, thus keeping girls in school, and the provision of life schools to transform life [28]. Through One Plan, the Government tries to expand youth-friendly services, not only by improving infrastructure, and supplies, but also by reorienting health staff in compassionate care, patient charter, and rights of adolescents [25]. Moreover, the country through National Accelerated Action And Investment Agenda For Adolescent Health And Wellbeing NAIA-AHW) (2021/2022–2024/2025) focuses on accelerating the improvement of adolescent health and wellbeing to support the growth and development of health [29]. To achieve this vision, the Agenda is anchored on six pillars that represent issues that affect adolescents disproportionately, namely: preventing HIV; preventing teenage pregnancies; preventing sexual, physical, and emotional violence; improving nutrition; keeping boys and girls in school; and developing skills for meaningful economic opportunities [15, 30].

Despite the country of Tanzania and other stakeholders are making efforts to ensure the well-being of adolescents and youth, they still experience significantly limited access to adolescent and youth-friendly SRHR information, education, and services [31, 32]. There may be some unanswered questions to whether the prescribed SRH plans and guidelines are implemented adequately or not [22, 33]. This study aimed at using a triangulation technique of data collection activities to examine functional sexual and reproductive health and right-based friendly services as perceived by exit adolescents, caregivers, and health workers at health services delivery points in Tanzania.

Methods and materials

Study area and design

This was a multicentric study among 205 randomly selected participants in eleven selected health facilities within the three regions of Tanzania including Dar es Salaam, Dodoma, and Kigoma regions using a one-time descriptive cross-sectional design with a quantitative research approach from 01 to 30 November 2022. The study covered a sample of health services delivery points (SDPs) located in the respective aforementioned regions.

Sampling procedures

Sampling procedures including the recruitment of health facilities and the study population based on the recommendations by some previous scholarly works [8, 34–38].

Health facilities

Non-probability sampling teching by a criterion purposive sampling method was used to select eleven health facilities from the respective aforementioned regions as they were the ones approved by the Tanzanian Ministry of Health to deliver functional sexual and reproductive health and right-based friendly services in the country. Ownership inclusion criteria weas used to stratify Public (n = 8) and Private (n = 3) health facilities during the sampling activities.

Study population and sample size determination

The study focused on both males and females as they were the ones who would share their opinions on matters around sexual and reproductive health service provision and establish a diversified and representative reality about the matter based on sex. The study recruited and assesed 205 participants who were then proportionally distributed to the selected health facilities using the proportionate formula , to establish strata including exit adolescent clients (n = 47), adolescent respondents from surrounding communities (n = 47), and adult exit clients (n = 47), adult respondents from surrounding communities (n = 47). The assessment also targeted conducting client-provider interaction observations (n = 19), conducting health services delivery point inventory observations (n = 11), assessing health-care providers (n = 11), assessing the health facility manager (n = 11), and assessing health services delivery point support staff (n = 12). A voluntary basis was used as a criterion for the participants to join the study and thus study respondents were free to withdraw from the study at any point without being questioned and his/her information not processed and analysed. All participants provided written informed consents to participate in the study. Adolescents who were below the age of 18 years, legally acceptable representative such parents or relatives consented on their behalf.

Data collection tools

The study adapted tools from the Tanzanian Ministry of Health that have been customized from the global standard tools for assessing the availability and accessibility of adolescent and youth-friendly sexual and reproductive health services. These tools have been designed to gather information about standards’ criteria from different stakeholders (facility managers, healthcare providers, support staff, adolescent clients, adolescents in the community, gatekeepers in the facility, and gatekeepers in the community), as well as from documentary review and direct observation of the care process. Facility compliance with quality standards is then reflected in the aggregate scores per each standard (out of 100%). Examples of dependability include the consistency of a research study, a measuring test, or the instrument’s stability during the course of a research endeavor. citing certain earlier research [1, 2, 9], to avoid gaps in these studies, the structure, answerability, accuracy, correct completion of the questionnaire among the study respondents daily, duration, and completeness of filling out the questionnaires were used to determine the study’s reliability through a pretest of the questionnaires [39]. The pretest results were subjected to an exploratory factor analysis to examine the weight, sufficiency, and significant correlation of each item at a Kaiser Mayer Oklin (KMO) > 0.5 and a significance level for Bartlett’s test 0.05 to characterize the outcome variables of interest. The internal consistency of the instruments was then assessed using the scale analysis, which resulted to a Cronbach alpha of 0.79 that as recommended by some previous scholars [40, 41] was then regarded as adequate and dependable for the actual field data collection.

Data quality assurance

As suggested by other scholars [34, 42], to facilitate the collection and compilation of high-quality primary data including the determination and screening of anomalies from the collected information was built into the data collection process. Foremost, the data collectors recruited for this study were oriented to the objective of the study, the types of information they were required to collect; and to facilitate collection of high-quality data all information was quality audited daily. Data quality assurance for this study included sharing preliminary results with the Ministry of Health and Adolescent and Youth Friendly Services stakeholders during the validation stage where key stakeholders would review the draft report and further enhance the quality of data collected by correcting factual errors, errors of interpretation, and adding any other missing evidence.

Data collection procedures

The study employed a trangulation technique to collect data from the study participants including an observation checklist and questionnaires interviews adopted from the Tanzanian Ministry of Health, which are used to assess service provisions in health facilities. The data collection process triangulated various primary sources related to the program for Improving Access to Sustainable Quality of Integrated Sexual and Reproductive Health and Rights Services to adolescents, women, and girls, through Health System Strengthening in Tanzania. Before the commencement of the study, the research team consulted with the Ministry of Health staff and thoroughly discussed the scope of the study to familiarize them with it and the data collection tools.

Moreover, this study used observations, which during the implementation of the study, all observation activities were conducted in two settings, namely during adolescent client interaction with a Health-service provider; and during a transect walk to verify the facility inventory. The information collected while observing events or verifying inventories is important for measuring the quality of services provided by the facilities. Before the commencement of the client-provider interaction observation, permission was sought from both the service provider and the client. Permission/consent was sought from the respective Health services delivery point manager before the commencement of the inventory checklist.

Variable measurements

The scoring of the majority of the data elements of the standards criterion was based on a point system in which low points, “0”, were assigned to answers/items indicating sexual and reproductive health-friendly services not available/accessible, and high points, “1”, were assigned to answers/items indicating services were available and provided. In some instances, the relative value of the observation vis-a-vis other data sources was moderated by applying “weighted” scores. A score per standard is presented as a percentage of the maximum possible score and was calculated by quantifying the information collected on the standard from each data source and then averaging all of the scores from each data source.

Data management and analysis

The collected data was electronically captured using the IBM Statistical Package for the Social Sciences version 26 data entry templates (SPSS − 26) as it has been used as recommended by previous studies [35, 43]. The data analysis for this study was guided by both the objectives of the study and inputs from the Global Standards for Quality Health-Care Services for Adolescents Volume 4 scoring sheets for data analysis. During data analysis, data triangulation techniques were applied to strengthen the credibility and validity of the findings, judgments, and conclusions obtained. The analysis was mostly conducted using descriptive analysis model by Chi-square and cross-tabulations to establish uni-variate and bivariate frequencies and percentages. Findings have been presented using tables and figures.

Results

This section provides detailed descriptions of the results about the coverage and implementation fidelity of Functional sexual and reproductive health and right-based friendly services at the service delivery points including Dar es Salaam, Dodoma, and Kigoma regions from 13 to 30 November 2022. Response rate of the study was 100%.

Functional sexual and reproductive health and right-based friendly services delivery points

Results in Table 1 indicate that the health services delivery points covered by the Adolescent and Youth Friendly Services were assessed in eleven health facilities from the four districts that were sampled from three regions. The facilities included three dispensaries (27%) of which one was from Dodoma City Council (DCC); another from Kasuku Town Council (KTC) and the third was from Kigima Municipal Council (KMC). Moreover, there were six health centers (55%), three of which were sampled from Kinondoni Municipal Council; one from Dodoma City Council, and two from Kigima Municipal Council. The study also, sampled two hospitals (18%) of which one was from Dodoma City Council and the second from Kigoma Municipal Council. Most of these health facilities, nine to be specific (82%) were owned by the Government/ Local Government Authorities (LGAs), and two (18%) were owned by Faith-Based Organizations (FBOs).

Table 1.

Functional sexual and reproductive health and right-based friendly services services delivery points (n = 11)

Region	LGAS	Dispensary n = 3 (27%)	Health Center N = 6 (55%)	Hospital N = 2 (18%)
Dar es Salaam	Kinondoni MC	0	Kigogo HC	0
			Magomeni HC
			Tandale HC
Dodoma	Dodoma CC	Kikuyu disp.	Makole HC	St Gemma DDH
Kigoma	Kasulu TC	Murufiti disp.	0	0
	Kigoma MC	Kigoma disp.	Gungu HC	Baptist CDH
			Ujiji HC

The proportion of adolescents and youth perspectives on the availability of functional SRH right-based adolescent and youth-friendly services at health services delivery points

Results in Fig. 1 show that on average, exit male adolescents; female adolescents assessed in the communities; exit male community members; and male community members in the communities were slightly more likely (46%), (55%), (57%), and (85%) to confirm the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points than their counterparts respectively. These suggest some discrepancies in the operationalization of the Clients/Patient Charter and other existing adolescent rights policy directives, equity gaps, and sex inequalities to the accessibility of functional SRH right-based adolescent and youth-friendly services at the health services delivery points. This information is summarised in the figure.

Fig. 1.

The proportion of adolescents and youth perspectives on the availability of functional SRH right-based adolescent and youth-friendly services at health services delivery points

The proportion of health workers’ perspectives on the availability of functional SRH right-based adolescent and youth-friendly services at health services delivery points

As shown in Fig. 2 results depict that health workers in hospitals were more likely (86%) to confirm the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points than health centers (65%) and dispensaries (60%). This information is summarised in the figure.

Fig. 2.

The proportion of health workers’ perspectives on the availability of functional SRH right-based adolescent and youth-friendly services at health services delivery points

The proportion of exit adolescents at health services delivery points who reported various aspects of functional SRH right-based adolescent and youth-friendly services

Results in Fig. 3 show that among the services exit female and male adolescents and youth, the results showed services exit male adolescents were more likely (100%) than services exit female adolescents (56%) to note services are provided to all adolescents without discrimination at the health services delivery points. The results also showed services exit male adolescents were more likely (83%) than services exit female adolescents (59%) to narrate at least three of the adolescent rights. The results also noted exit female adolescents and youth are more likely (6%) than exit male adolescents and youth (0%) to see information about adolescents’ rights displayed at the health services delivery points. It was also noted, that exit female adolescents and youth are more likely (5%) than exit male adolescents and youth (0%) to see information about confidentiality policy displayed at the health services delivery points. This information is further elaborated in the figure.

Fig. 3.

Proportion of exit adolescents at health services delivery points who reported various aspects of functional SRH right-based adolescent and youth-friendly services

The proportion of adolescents in the communities who reported various aspects of functional SRH right-based adolescent and youth-friendly services

Results in Fig. 4 show that both female and male adolescents equally (100%) recalled the Health-service providers at the health-service delivery points they visited the last time were friendly. They also showed female adolescents were more likely (78%) than male adolescents (44%) to narrate at least three of the adolescent rights. It was also noted female adolescents were more likely (50%) than male adolescents (0%) to have seen a display at the health services delivery points informing those services are provided to all adolescents without discrimination. The results also highlighted that female adolescents and youth interviewed in the communities are more likely (44%) than male adolescents and youth assessed in the communities (0%) to have ever seen information about adolescents’ rights displayed at health services delivery points. The results also showed male adolescents and youth assessed in the communities are more likely (56%) than female adolescents and youth assessed in the communities (28%) to have ever experienced other people being allowed to enter the consultation room while they were still being served at health services delivery points. Lastly, the results noted female adolescents and youth interviewed in the communities are more likely (28%) than male adolescents and youth interviewed in the communities (0%) to have ever seen confidentiality policy information displayed at health services delivery points. Figure 4 below shares these insights on the differentials among female and male adolescents and youth interviewed in the communities.

Fig. 4.

Proportion of adolescents in the communities who reported various aspects of functional SRH right-based adolescent and youth-friendly services

The proportion of exit community members who reported various aspects of functional SRH right-based adolescent and youth-friendly services

Foremost, the results in Fig. 5 show that services exit male community members were more likely (95%) than services exit female community members (64%) to know it is important to provide health services to adolescents. The results also noted services exit male community members were more likely (74%) than services exit female community members (46%) to have ever discussed with a Health-service provider about the services available for adolescents. It was also noted services exit female community members were slightly more likely (46%) than services exit male community members (42%) to know health services are provided to adolescents at the health services delivery points. The finding further notes services exit females are more likely (36%) than services exit males (16%) to acknowledge an adolescent/youth from their households has ever used health services at health services delivery points. This information is summarised in the figure.

Fig. 5.

Proportion of exit community members who reported various aspects of functional SRH right-based adolescent and youth-friendly services

The proportion of community members who reported various aspects of functional SRH right-based adolescent and youth-friendly services

As shown by the results in Fig. 6 from among female and male community members interviewed in the communities, it was found that male community members were more likely (100%) than female community members (93%) to know it is important to provide services to adolescents. It was found male community members are slightly more likely (86%) than female community members (83%) to know where adolescents in the community can get health services. The results also showed male community members were more likely (68%) than female community members (39%) to have ever discussed with health service providers the services available for adolescents. This information is summarised in the figure.

Fig. 6.

Proportion of community members who reported various aspects of functional SRH right-based adolescent and youth-friendly services

The proportion of health services delivery points that reported various aspects of functional SRH right-based adolescent and youth-friendly services

The results shown in Fig. 7 indicate that all in charge (100%) confirmed their SDPs keep case records in a secure place, accessible only to authorized personnel. It was noted that in-charges at hospitals and dispensaries were more likely (100%) than in charges at health centers (67%) to confirm that the SDPs staff do not disclose to third parties any information given to or received from adolescents. The results also showed that charges at hospitals and dispensaries were more likely (100%) than in charges at health centers (67%) to confirm SDP staff are trained in adolescent health and human rights. It was further found That charges at the hospital were more likely (100%) than in charges at health centers and dispensaries (67%) to confirm that Information on the identity and the presenting issue of adolescents are gathered in confidence at SDPs. Furthermore, in-charges at the hospital were more likely (100%) than charges at health centers (50%) and dispensaries (0%) to confirm the information on policy on confidentiality and privacy was displayed at SDPs. Last but not least, In charges at the hospital were more likely (50%) than in charges at health centers (67%) and dispensaries (0%) to confirm information on the rights of adolescents to information, non-judgmental attitude and respectfully displayed at SDPs. This information is summarised in the figure.

Fig. 7.

Proportion of health services delivery points that reported various aspects of functional SRH right-based adolescent and youth-friendly services

The proportion of health services providers who know various aspects of functional SRH right-based adolescent and youth-friendly services

Results in Fig. 8 show that all (100%) Health-service providers confirmed to have policy guidelines on privacy and confidentiality during service provision; and to know the importance of respecting the rights of adolescents to information and health care. It was also found that Health-service providers at hospitals and health centers (100%) are more likely than Health-service providers at dispensaries (67%) to know the measures to protect the privacy and confidentiality of adolescents. The results also show that Health-service providers at hospitals (100%) are more likely than Health-service providers at health centers (83%) and dispensaries (67%) to be aware of available guidelines/Standard Operating Procedures (SOPs) on measures to protect the privacy and confidentiality of adolescents. This information is summarised in the figure.

Fig. 8.

Proportion of health services providers who know various aspects of functional SRH right-based adolescent and youth-friendly services

The proportion of health services delivery points that reported various aspects of functional SRH right-based adolescent and youth-friendly services

The results in Fig. 9 show that Hospitals are more likely (100%) than health Centres (67%) and dispensaries (33%) to have information on policy on free or affordable service provision for adolescents displayed at the SDPs. It was also noted Hospitals are more likely (83%) than Health Centres (50%) and dispensaries (33%) to have information on clients’ rights displayed and available at the SDPs. The results also documented Dispensaries are more likely (100%) than Hospitals (50%) and Health Centres (50%) to have records on orientation on the importance of respecting the rights of adolescents’ information available at the SDPs. The assessment also found Hospitals are more likely (50%) than health Centres (33%) and dispensaries (33%) to have the rights of adolescents to information, non-judgmental attitude, and respectful care available at the SDPs. It was also noted Hospitals are more likely (50%) than health Centres (33%) and dispensaries (0%) to have guidelines/SOPs on protecting the privacy and confidentiality of adolescents available at the SDPs. Last but not least, the assessment also found Hospitals are more likely (50%) than health Centres (0%) and dispensaries (0%) to have a policy commitment to provide health services to all adolescents available at the SDPs. This information is summarised in the figure.

Fig. 9.

Proportional distribution of aspects of functional right-based adolescents and youth-friendly services available at service delivery points

Distribution of the mean score for each of the National standards for provision of quality functional SRH right-based adolescent and youth-friendly services across the 11 SDPs

The results documented in Table 2 about the aspects of functional right-based youth-friendly services at health services delivery points show that the highest across all 11 health services provision points, Standard II (parents and community support) recorded the highest score, closely followed by Standard I (Adolescents’ Health Literacy) and Standard VII (Data and Quality Service Improvement); and the lowest score was Standard VIII (adolescents’ participation); with Standards III, IV, V and VI lying in between. These results may imply that none of the eight National standards for provision of quality functional SRH right-based adolescent and youth-friendly services scored 100%. However, a marked variation of scores of each of the National standards for the provision of quality functional SRH right-based adolescent and youth-friendly services was marked, with Standard I recording the least variation (standard deviation = 6.8%). The results suggest that this standard consistently scored values closer to the mean score of 65%. On the other hand, Standard VI recorded the highest variation (standard deviation = 19.8%) suggesting that this standard was scored with values widely spread from the mean score of 63%.

Table 2.

Distribution of the mean score for each of the National standards for the provision of quality functional SRH right-based adolescent and youth-friendly services across the 11 SDPs

Standard	Mean friendliness percentage score	Standard Deviation
Standard I	65.0%	6.8%
Standard II	66.3%	9.8%
Standard III	54.0%	13.8%
Standard IV	57.1%	10.7%
Standard V	60.2%	7.2%
Standard VI	62.8%	19.8%
Standard VII	64.8%	14.9%
Standard VIII	46.1%	13.6%

Distribution of the average score for each of the 11 SDPs across all eight National standards for the provision of quality functional SRH right-based adolescent and youth-friendly services

The results in Table 3 show that Tandale HC scored the highest with an average of 73% closely followed by Kigogo HC (71%), Ujiji HC (67%), and Baptist CDH (65%). The lowest scores were recorded at Murufiti Dispensary (43%), Kikuyu Dispensary (48%), and Kigoma Dispensary (54%). A marked variation of scores of the eight National standards for the provision of quality SRH services to adolescents was observed for each of the 11 Health Services Delivery Points. Magomeni HC was found to have the lowest level of variation by scoring consistent values for the entire eight standards (standard deviation = 5.8%) with values closer to the mean score of 59%.

Table 3.

Distribution of the average score for each of the 11 SDPs across all eight National standards for the provision of quality functional SRH right-based adolescent and youth-friendly services

SDPs	Mean friendliness percentage score	Standard Deviation
Murufiti Disp.	42.8%	9.1%
Kikuyu Disp.	48.0%	17.2%
Kigoma Disp.	53.9%	11.9%
Gungu HC	58.2%	8.6%
St Gemma DDH	58.4%	14.8%
Makole HC	58.9%	12.7%
Magomeni HC	59.4%	5.8%
Baptist CDH	64.6%	12.1%
Ujiji HC	66.8%	7.6%
Kigogo HC	71.0%	12.5%
Tandale HC	72.8%	7.0%

Furthermore, Kikuyu Dispensary was found to have the highest level of variation by scoring inconsistent values for all eight standards (standard deviation = 17.2%) widely spread from the mean score of 48%. In this regard, Magomeni HC was the most consistent health service delivery point (SDP) in scoring the eight National standards for the provision of quality SRH services to adolescents, whereas Kikuyu Dispensary was the least consistent in scoring these standards during this assessment.

Discussion

This study examined functional sexual and reproductive health and right-based friendly services through the perspectives of exit adolescents, caregivers, and health workers at health services delivery points in Tanzania. The results indicated that on average; hospitals were more likely to secure the availability and accessibility of functional SRH right-based adolescent and youth-friendly services than health centers and dispensaries. This may probably be the case because structurally, higher-level health facilities in the country are much more populated with clients than other levels and thus, more efforts would be put into ensuring resources and services including functional adolescents and youth-friendly SRH services are available and accessible consistently. The observed results indicated that none of the 11 health services delivery points complied to delivering quality functional SRH right-based adolescent and youth-friendly services by a 100%.

Nevertheless, the results of this study uncovered that of the 11 health services delivery points assessed none of them scored 100% for any of the eight National standards for the provision of quality functional SRH right-based adolescent and youth-friendly services as set out by the National Standards and Implementation Guide for Quality Health Care Services for Adolescents. These results imply that adolescents may still experience missed opportunities in accessing comprehensive SRH education, information, and associated services. Moreover, the large variation in scores of the eight National standards for the provision of quality functional SRH right-based adolescent and youth-friendly services may serve as a signal of the presence of high levels of inequities in the provision of the services to adolescents and youth at the health delivery points. Additionally, the results of this study have revealed a sense that there is limited operationalization of the Clients/Patient Charter and other existing adolescent rights policy directives, gaps in equity, and some sex equalities on the availability and accessibility of adolescent and youth-friendly SRH services at the health services delivery points.

The results on participants’ perspectives on the availability and accessibility of functional adolescent and youth-friendly services show that on average, exit male adolescents were slightly more likely to confirm the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points than exit female adolescents. In contrary to males, female adolescents assessed in the communities were more likely to confirm the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points. On the other hand, results also showed that on average males and exit male community members were more likely to confirm the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points than exit female community members. These results suggest that the exposure to the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points was higher for male exit clients than for female exit clients.

Results observed in this study suggest that there was no significant consistency in the perscpectives of study participants on the availability and accessibility of the functional adolescent and youth-friendly SRH services at the health services delivery points. Given the need and health seeking behavior among adolescents and youths in the country, the diversity of perspectives would probably be attributed by the difference in participants strata of which exit adolescents in the health facilities would perceive the availability and accessibility of the services differently from those in the community.

The results of this study match with some other previous scholarly works around the globe. A case study conducted by Mwanangombe et al., [16] in Zambia accessed the utilization of sexual and reproductive health services among adolescents. Results revealed that if the services are available and accessible in health facilities adolescents’ practices in using them increase tremendously. Their results may imply that adherence to the implementation of national guidelines and standards in the provision of adolescent and Youth-Friendly Sexual and Reproductive health may help to address unmet needs and opportunities for sexual information, education, and related services to young people including adolescents and youth.

A qualitative study conducted by Mgopa et al., [27] on the perceptions of sexual and reproductive health provision in Tanzania found that adolescents and youth missed opportunities to access some sexual and reproductive health information, education, and services from health facilities. The prominent reported contributing factors included among others the inadequacies in health policies, guidelines, and standards implementations in the provision of those services to adolescents and youth. Moreover, their results highlighted that a lack of training about national guidelines and standards among healthcare providers catalyzed limited access to friendly SRH services among adolescents and youth. Addressing these pitfalls seemed to be an ideal solution to addressing young people’s unmet SRH needs.

Getachew et al., [11] conducted a cross-sectional study on young people’s friendly SRH services knowledge, attitude, and practices in South-Western Ethiopia. Results revealed that the majority of the study participants have low knowledge, and negative attitudes and do not seek and use adolescent and youth-friendly SRH services from health facilities. They concluded that the overall utilization of friendly SRH services among adolescents and youth was poor, which was closely linked with personal-related factors including sex and education levels. However, the trend would also be connected with the availability and accessibility of adolescent and youth-friendly SRH services in health facilities.

There are more previous observational and interventional scholarly works of the same nature including those conducted by Millanzi et al., [1, 2, 8, 24, 30, 31, 38] in Tanzania demonstrate the trend of SHR matters among adolescents that need to be addressed accordingly. Results of these works show that the majority of adolescents are not to be blamed for engaging in early sexual activities; getting early and unintended pregnancies and children; getting infected with HIV and Sexually Transmitted Infections and school dropouts. They lack timely and age-appropriate SRH information, education, and associated services from reliable sources including parents/relatives; teachers, and health workers in health facilities. The presence of national SRH guidelines and standards with adequate and proper implementations by competent healthcare providers in health facilities may guarantee the coverage and their uptake among adolescents and youth.

Nevertheless, Ndayishimiye et al., [23] conducted a descriptive cross-sectional study on the availability, accessibility, and quality of adolescent and youth-friendly SRH services in the health facilities available in Rwanda. The results of their study showed that although the SRH services were available in almost all health facilities their accessibility remained limited to adolescents and youth who resided in the respective area. It was highlighted that consistent and appropriate implementation of the SRH guidelines and standards and involving adolescents and youth in the first position during planning activities of the SRH services in health facilities may guarantee their uptake among adolescents and youth.

The similarities of the previous scholarly works with the current study demonstrate common observations that adolescents and youth are eligible and have rights to access age-appropriate and friendly SRH information, and education for cognition, affection, and life skills to navigate SRH challenges in their day-to-day lives. Moreover, it has been revealed that they have the right to access age-appropriate and friendly SRH services from competent and appropriate workers from health facilities. The matching between these studies might probably be attributed to the similarities in the study context, population, and methodologies.

Conclusion

The results of this study have uncovered that there is disperities in the availability and accessibility of functional SRH right-based adolescent and youth-friendly services across the levels of health facilities; among adolescents and community members. However, none of the health services delivery points covered by the assessment delivered functional SRH right-based adolescent and youth-friendly services adolescent-youth friendly by a 100%. Given that more dispensaries and health centers were covered with functional adolescents and youth-friendly SRH services than hospitals; sex differentials on confirmation of the availability of the services were noted among female and male exit clients in hospitals than in other levels of health facilities. On average, exit male adolescents, youth, and community members were more likely to confirm the availability of functional SRH right-based adolescent and youth-friendly services adolescent-youth friendly at the health services delivery points than exit female adolescents, youth, and community members.

These results suggest that the exposure to the availability of functional SRH right-based adolescent and youth-friendly services at the health services delivery points was higher for male exit clients than for female exit clients. Contrarily, in the communities, the availability of functional SRH right-based adolescent and youth-friendly services adolescent-youth friendly at the health services delivery points was noted to increase with age; more among adult community members than among the younger community members, namely the adolescents and youth. Based on the results observed in this study, there appears a need to address issues of differentials in equity to the accessibility of services among adolescents, youth, and community members by improving functional sexual and reproductive health and right-based friendly services provision infrastructures, health care workers capacity building, and mechanisms or approaches to increase adolescents’ access and uptake to SRHR services.

To level off the equity issues and the sex inequalities, the Ministry of Health, implementing partners, and other adolescent and youth sexual reproductive health stakeholders will need to address the issues about the non-availability of adolescents’ rights policy documents and availability of health services providers oriented on the importance of respecting the rights of adolescents’ information at the health services delivery points. To cap up all the differentials on the availability of Functional Right Based Youth Friendly Services at the health services delivery points, the Ministry of Health, implementing partners and other adolescent and youth sexual reproductive health stakeholders should continue strengthening the provision of quality adolescents’ and youth health services through quality improvement initiatives that are stipulated in national guidelines including the National Standards and Implementation Guide for Quality Health Care Services for Adolescents needs.

Limitations of the study

Being a study that assessed sensitive topic on the availability and accessibility of functional sexual and reproductive health and right-based friendly services by assessing the perspectives from exit adolescents, caregivers, and health workers at health services delivery points in Tanzania, there might be some degrees of recall bias, under or over information from them, though not to a higher degree but may need to be considerd when interpreting these results. Additionally, prescriptions on the methods and materials used in this study might not be sufficiently and accurately documented to allow replication studies and thus attention may be needed linking the methodological activities and results of the study.

Abbreviations

AYFHS

Adolescent and Youth-Friendly Health Services

CC

City Council

CDH

Council Designated Hospital

DDH

Designated District Hospital

SRHR

Sexual and Reproductive Health Rights

HIV

Human Immunodeficiency Virus

HC

Health Center

HSSP

Health Sector Strategic Plan

MC

Municipal Council

NAIA-AHW

National Accelerated Action And Investment Agenda For Adolescent Health And Wellbeing

NBS

Nation Bureau Statistics

RMNCAH

Reproductive, Maternal, Newborn, Child and Adolescent Health

RRH

Regional Referral Hospital

SPSS

Statistical Package for Social Sciences

SRH

Sexual and Reproductive Health

SRHS

Sexual and Reproductive Health Services

VAWC

Violence Against Women and Children

YFS

Youth-Friendly services

Authors’ contributions

G.K.: Conceptualization, methods and materials, conduct of the study, data curation, and analysisM.N.M.: Conceptualization, methods and materials, conduct of the study, data curation, and analysisW.C.M.: Conceptualization, methods and materials, data curation, and analysis, writing and editing the original draft of the workThe author has read and approved the manuscript.

Funding

This work has not been externally awarded and the authors have not received any financial grant from the government or other organizations. The work was privately sponsored.

Data availability

Examining functional sexual and reproductive health and right-based friendly services: Perspectives from exit adolescents, caregivers, and health workers at health services delivery points in Tanzania.

Declarations

Ethics approval and consent to participate

Legal approval: The Youth Friendly Services Assessment was conducted as an operations research that did not require an official ethical clearance, and just required approval and authorization from the Ministry of Health and the President’s Office Regional Administrations and Local Governments at the central level; and the engagement of the Regional Administrative Secretaries, District Executive Officers, Health services delivery point In charges and Community Leaders.

Informed consent: All respondents who were covered by the Youth Friendly Services Assessment were informed about the content and the purpose of the assessment before the commencement of interviews. Informed consent was also requested before the commencement of an observation schedule. In this regard, all key informants willingly agreed to participate in the Youth Friendly Services Assessment.

Confidentiality: Confidentiality was also observed during the Youth Friendly Services Assessment for all respondents who were involved in the key informants’ interviews. Each one was interviewed separately and all the collected information was stored in strict confidence.

Data storage, data safety, and security: All primary assessment data was collected on paper and kept in good custody before being transported to the Ministry of Health headquarters in Dodoma for electronic data capture. For the sake of data storage, data safety, and security, all data notes that were collected on paper were stored in locked cupboards, whereas all digitally collected data was stored on password-protected computers. All unnecessary data documents which had already been accessed and data extracted from them were destroyed by shredding.

Compensation (type and amount): The study participants received no compensation of any type or amount because the study was implemented alongside the respective training institutions’ academic calendars, which they were informed of before the start of the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.