Adolescent health services in a primary care facility in Northern Ghana: a qualitative investigation of patients’, guardians’, and staff’s perceptions of care

Abstract

Background

Ghana’s population of 30.8 million people is predominantly young, with a median and mean age of 21 and 25.2 years, respectively. Yet, there are limited studies on quality of clinical care for Adolescent and Young Adult (AYA) aged 10-24years in Ghana. To better understand facility-level barriers and facilitators to AYA primary care, we conducted a qualitative study at the Tamale Teaching Hospital polyclinic as part of a broader quality improvement initiative for young people care.

Methods

Convenience sampling was used to identify and recruit 12 AYAs, 8 guardians, and 22 staff for in-depth interviews and focus group discussions. In-depth interviews were conducted with AYAs and guardians and focus group discussions were conducted with staff. Interviews and focus group discussions explored topics including previous care experiences and reasons for visits, experiences and perceptions of service at registration or booking points, nursing services, consultations with doctors, services at the laboratory, pharmacy, and cash payment point. The study employed inductive and deductive reflexive thematic analysis of interviews and focus group discussions. All qualitative data were transcribed. The qualitative software NVivo 14 was used for coding and theme development.

Results

Five themes emerged: Healthcare quality and accessibility, systemic and administrative challenges, Autonomy, confidentiality and privacy, adolescent health conditions and needs, and participants’ perspectives on improvement. The major barriers to adolescent responsive care are system inefficiencies and negative staff attitudes, and the major facilitators are trust and confidence in doctors’ competence, perceived superior care in a Teaching Hospital, and convenient services and proximity.

Conclusion

AYA and guardians want convenient, easily accessible and high-quality care, delivered by a friendly and trusted team, which views the healthcare workers also endorsed. There is a need for training of healthcare staff in adolescent friendly and responsive services, as well as facility level reforms and restructuring of mainstream services to make them more appropriate and responsive to the needs of this population.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14077-1.

Background

Adolescents are people between the ages of 10–19 years, while Young Adults are people between the ages of 20-24years [1, 2]. The World Health Organization (WHO) again defines the age group 10–24 years as young people (age 10–19 as adolescents and age 20–24 as youth or young Adults) and Neinstein et al. defines this age group as adolescents and young adults (AYA). The healthcare needs of this age group range from communicable to noncommunicable diseases, nutritional, intentional and unintentional injury, substance use, and sexual and reproductive health [1–4].

According to the World Health Organization, adolescents are least well served by existing health services [1]. Although globally, efforts towards quality adolescent healthcare have been made, progress is slow. Out of the 109 countries reviewed by WHO, three-quarters of existing services only focused on sexual and reproductive health. The lack of comprehensive and integrated approaches also makes these existing efforts weak [1]. A systematic review by Jonas et al. on studies done in seventeen [17] Sub-Saharan African countries between 1990 and 2015 revealed that negative healthcare worker attitude, low level of knowledge of healthcare workers and cultural and religious beliefs were barriers to access and quality of sexual and reproductive services among adolescents [5]. The situation in Ghana is similar [6]. Agblevor et al. also found that only 4 (17%) out of the 23 stated strategies and programs in the National Adolescent Health Service Policy and Strategy (AHSPS) were fully implemented, with limited integration of youth programming into general mainstream services of the Ghanaian healthcare system [7].

Many factors affect the dynamics of adolescent healthcare. Firstly, adolescence is a period of rapid biological and psychosocial growth with behavioural patterns that make the health risks and implications of this group unique. Adolescents may look mature physically, yet their cognitive control networks for relational reasoning are not mature. So they explore, experiment and take risks in affective social context, often with poor planning, judgment, and control [1, 8–14]. At times, peer influence from adolescents with antisocial behaviours worsens the risk profile. Healthcare workers must have a good understanding of these unique characteristics of adolescence and the inherent behavioural patterns and health implications to enable them to serve them well. Therefore, a responsive healthcare system ought to have healthcare workers who are knowledgeable, non-judgmental, considerate, easy to approach, and trustworthy. The services should also be affordable, convenient, accessible, and appropriate to meet al.l their needs [4].

Secondly, parents, guardians, and the community also act as gatekeepers in adolescents’ lives. Societal norms prescribe what is acceptable and often frown at premarital sex, and contraceptive use is often forbidden. Such societal norms can contribute to unintended pregnancies and unsafe abortions among adolescents. Community perceptions formed from these norms, and home environment, power structure, and rules all heavily influence adolescent healthcare choices, health literacy, acceptance, patronage, or rejection of health services [1, 15–22].

Thirdly, healthcare systems and facility-specific characteristics can either enhance or hinder quality healthcare for adolescents and young adults. Adolescents generally prefer services that are convenient, affordable, and accessible. They also want it to be offered by a competent adolescent-friendly healthcare provider [23]. Traditionally, healthcare system infrastructure and training are often tailored towards pediatric and adult patients. The care may be accessible but hostile and not affordable or not convenient because it does not support adolescent comfort, autonomy, privacy, and confidentiality [20, 24, 25]. There is also a healthcare provider knowledge gap, and again a lack of and/or ineffective health-protecting and promotive policies and laws for adolescents.

Fourthly, health literacy is key to adolescent empowerment. The 2016–2020 Ghanaian Adolescent Health Service Policy and Strategy situation analysis of adolescent healthcare indicated that adolescents in Ghana have poor access to appropriate health information, and their utilization of health services is also poor. As already stated, the implementation of the policy guidelines remains a big challenge, and adolescent health literacy remains low [7, 20, 26]. There is a gap in research evidence on the interplay of these factors on the range of primary care clinical services in Ghana and their impact on quality clinical care to adolescents. The aim of the study was to understand staff,’ Guardians’, and AYAs’ perception of the clinical services offered to Adolescents at Tamale Teaching Hospital (TTH) Polyclinic to enable us to ascertain the perceived facility-specific characteristics and staff-related issues that enhance or hinder quality healthcare delivery to adolescents and young adults, and how to improve upon or establish needed services.

Methods

Study design

We employed a qualitative reflexive thematic analysis approach, utilizing interview guides to conduct in-depth interviews and focus group discussions to gain insights into the experiences, perceptions, and opinions of AYAs, guardians, and healthcare staff on AYA health services at the TTH Polyclinic. The study was conducted and reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ). The COREQ checklist is filled and submitted separately as a supplementary file. Details of the interviews and focus group discussion are captured under the procedure section. The foundational element that informed the design of the interview guide came from the Ghana National Adolescent Health Service Policy and Strategy’s quest in using research evidence relevant to the local context to inform practice [26]. Secondly, globally accepted patient engagement concepts for safe and quality clinical services at the primary care level through surveys and interviews were incorporated into the design to give opportunity to participants to offer useful insights on ways to improve AYA services [27–32]. Also, existing literature on adolescent health services in Ghana and at regional level were also reviewed to inform relevant areas to include in the interview guide. Socioecological theory on Adolescents’ life course was also relevant in understanding the gate keeper effect and its influence on adolescents’ healthcare choices and decision-making [5, 15–22]. Three different interview guides, one for each group were used. This allowed us to have different questions relevant to each participant group. They are submitted as one document separately as a supplementary file.

Study setting

The study was conducted at the Tamale Teaching Hospital Polyclinic, a primary care facility located in Tamale Metropolis in northern Ghana. This city is the fastest growing city in West Africa and has large AYA population due to urbanization [33, 34]. The Polyclinic is situated within a teaching hospital and was rated by the study team as the best site among the facilities for the study objectives as it serves as the primary entry point to the teaching hospital for AYAs. Tamale Teaching Hospital is the only teaching hospital in Northern Ghana, and AYAs within Northern Region as well as those from other regions come through the Polyclinic.

The Polyclinic has healthcare workers such as nurses and midwives, physician assistants, medical officers, and family physicians and therefore resembles the other primary care facilities in the country. It has a 32-bed capacity for inpatient care. The study also focused on understanding the facility’s strengths and challenges in meeting the unique needs of adolescent patients. The interviews were conducted in quiet private room within the Polyclinic ward.

Sample size

The study recruited a total of 42 participants, comprising 12 adolescent and young adult patients, 8 guardians, and 22 healthcare staff members. The stated numbers of participants in each data set achieved depth, richness, and diversity.

Participants

The recruited AYAs and their guardians were patients who had visited the Polyclinic at least once in the previous year for healthcare reasons. At the time of recruitment, they had come to seek healthcare services at the Polyclinic. Three inpatients and one outpatient declined to participate. Of the AYAs recruited, the age range was from 14 years to 24 years. Age group 10–13 years were excluded because those between the ages of 10–12 years are seen at the Pediatrics and Child Health Department, and an attempt to interview a 13-year-old who assented and parent consented did not prove fruitful. 4 received both inpatient and outpatient services, and 8 received only outpatient services. The staff were those who had worked there for at least one year. Three staff members declined to participate, citing that they were not interested.

Four focus groups were organized for the different cadres of staff. The nurses’ focus group consisted of 7 members, and the prescribers’ group comprised 6 members, including two family medicine residents, two medical officers, and two physician assistants. There were four managers: a nurse manager, an administrator, a pharmacy manager, and an accountant. The other staff focus group consisted of two laboratory staff, two health information staff, and one pharmacy staff member. The least years of work at the Polyclinic were two years, and the most were nine years.

Procedure

The research team consisted of four doctors, of which two were staff members of the Polyclinic and the other member was an administrator of the Polyclinic. Interviews were conducted by JAA, OS, AMA, MHK who are authors of this study. The Principal Investigator (JAA) is a male family physician specialist at the Polyclinic and had training in qualitative research, and the study team included two experts in this field. There were prior encounters with two inpatient participants interviewed. However, efforts were made to minimize social desirability bias, and where possible, we avoided recruiting and interviewing those with prior encounters with research staff. Convenience sampling of patients and guardians who had at least one visit to the Polyclinic in the past 12 months, and staff who had worked at the facility for at least one year, was done. The interview guide was designed, reviewed, pre-tested and revised by three people (JAA, SRI, MAB); one of whom has very good expertise in qualitative research. JAA, the principal investigator, did a pre-testing of the interview guide at the Polyclinic two weeks before the commencement of interviews.

This baseline study is aimed at understanding the factors that facilitate or hinder service delivery as well as the facility’s ability to deliver quality healthcare, both at Outpatient and inpatient, to AYAs. We also sought to understand the perception of healthcare providers on how the Polyclinic is doing in relation to service delivery to this group. So at least two staff members participated from all the service points of the Polyclinic. The participants were given the patient information leaflet to read, and the research staff provided an explanation in English to facilitate a clearer understanding. The interviews were done in a private room within the Polyclinic ward. Written consent was obtained from all adult participants and guardians of minors (youth under the age of 18) and written assent was obtained from minors. A verbal consent from AYAs at time of interview was done to ensure that they were not interviewed under duress.

Demographics of those who consented were first taken, and then they were interviewed using an open-ended interview guide. In-depth interviews were done for all 12 AYAs and 8 guardians to gain full insight into the rich and diverse lived experiences, perceptions, and suggestions. The focus groups were intended to ascertain the collective views and opinions of the designated staff groups, rather than individual experiences. The questions were structured in such a way as to ensure that responses covered the conditions they presented with, and if there were any unaddressed health problems that required healthcare provider attention. AYAs and guardians were seen as co-creators of quality and safe AYA health services and hence were given a voice through this study to help inform improvement and future redesign of the clinical service delivery at the facility. As such, the open-ended questions also sought to cover all service points and all categories of workers, and the physical layout of the place and organization of work. All participants were given the opportunity to contribute to any changes needed and to suggest the best way to plan and deliver healthcare services for AYAs. The data collection and analysis continued in each group until no new codes or themes emerged.

The interviews (both IDIs and FGDs) lasted a minimum of 30 min and a maximum of one [1] hour and were recorded using voice recorder and transcribed and themes generated using both NVivo 14 and manual approach. Note taking was also done during interviews by a second member of the research team and not the interviewer. The review of the manuscript was first done by three experienced researchers among the team and finally by one with long standing experience in qualitative research.

Analysis

The data sets for AYAs, Guardians, and staff were coded differently. The codes and themes generated from these data sets became the master data set. Theme commonalities were generated for this analytic direction. Reflexive thematic analysis, conducted by three analysts to reinforce rigor and quality, was performed using the six steps outlined by Braun and Clark [35–39]. In this analytic direction, our subjectivity was inclined towards narratives and supportive quotes for themes and not sub-themes, but we ensured that both scope and diversity of the themes were elaborated upon and supported with data extracts.

Patterns of meaning from the data were generated inductively and latent meaning akin to the conceptual frameworks and theory that guided design of the interview guides, familiarization, coding and themes development were reflexively incorporated. This resulted in five themes: Healthcare quality and accessibility, Systemic and Administrative Challenges, Autonomy, Confidentiality and Privacy, Adolescent Health Conditions and Needs, and Participants’ perspectives on improvement.

The write-up also employed both inductive and deductive meaningful generation of knowledge from the data sets and certain conceptual frameworks relevant to this study. The conceptual frameworks were integrated in a flexible and iterative manner during familiarisation, coding, and theme development. Understanding of the adolescent period and their unique behavior, perceptions, and decision-making patterns made behavioral science models very necessary. Verbal models such as social motivation, reward sensitization, and distraction were crucial in this regard. An increase in social motivation from high social value, validation, and acceptance is notably common among adolescents. And social influence from peers creates a dramatic effect on adolescent risk-taking, and the risky behaviour is often associated with altered representation of the reward, with poor self-control and diminished cognitive skills due to the immature cognitive control systems of the brain [8–14, 40].

The socioecological framework was needed for deductive analysis by aiding in the understanding of the gatekeeper effect of guardians and the community on their healthcare decision-making and interactions [20–22, 41]. Also, gatekeepers must seriously be considered in healthcare planning and implementation.

For the staff, we viewed the opportunities that exist for restructuring of care with the incorporation of the AYAs’ and guardians’ recommendations with the self-determination theory lens [42, 43]. Deductively, we assume that if there is inherent interest in becoming more competent and becoming an adolescent-friendly staff, as well as working innovatively to achieve this, then strategies that aim at satisfying these basic psychological needs from a self-determination theory perspective, such as autonomy support, relatedness support, and competence support, will greatly improve care.

Results

A total of 42 participants with male to female ratio of 1:1, consisting of 12 adolescents and young adult patients, 8 guardians and 22 healthcare staff participated in the study. The demographic characteristics of the participants are shown in Table 1.

Table 1.

Demographic data

Demographic data (N = 42)	AYA	Guardians	Healthcare staff	Total
Age Range (Frequency)	14–24 years (12)	32-64years (8)	28-55years (22)	(42)
Sex
Male	(4)	(3)	(14)	(21)
Female	(8)	(5)	(8)	(21)
Level of Education
JHS	(1)	(3)		(4)
SHS	(5)	(1)		(6)
Tertiary	(6)	(4)	(22)	(32)
Occupation
Unemployed	(11)	(4)		(15)
Employed	(1)	(4)	(22)	(27)
Type of Interaction
FGD	No	No	Yes	(22)
In-depth interview	Yes	Yes	No	(20)

Five themes emerged from the study: Healthcare quality and accessibility, Systemic and Administrative Challenges, Autonomy, Confidentiality and Privacy, Adolescent Health Conditions and Needs, and Participants’ perspectives on improvement.

Healthcare quality and accessibility

The quality of relationship and interactions in AYA healthcare was weighted higher and more valuable to adolescents and their guardians compared to staff-perceived privacy and confidentiality needs. Any disconnection or dismissive, unconcerned, rude, or inattentive behavior was seen as a serious barrier to quality healthcare delivery. Respect for patient dignity, values, and preferences, which are globally acclaimed as best strategies and underpin Patient Centered Care and Adolescent responsive service policy, was clearly demonstrated by this study as a key pillar of quality healthcare [4, 44–47]

Some of the nurses, although you have not yet spoken to them, but how they appear scares you a bit. So, like sometimes you come and you see a nurse and how she is moving, even her posture and her body language make you afraid to even approach her to ask her something. Yeah, some of them if they are talking, they don’t speak calmly, like they are shouting on you and they are just like authoritative. They are just doing, so it makes you feel scared to even approach them or ask them a question. And even if you want to, if you ask them a question and they are going to reply, you yourself, you will not be happy, like they’re shouting on you. IDI-AYA 7

It was also evident across the staff focus groups that some staff members’ attitudes towards AYAs were repulsive, rude, and created fear among AYAs and did not respect their dignity. The negative attitude or behaviour, which creates fear among AYAs as reported above, was a key indicator of poor performance in delivering healthcare to AYAs, especially among managers, prescribers, and other staff focus groups.

Very poor. Very, very poor. Yeah, because we see them as children. So, we treat them like children. In some of the consulting rooms, you go and the doctors shout at them. They come to the pharmacy, we talk anyhow to them because we think they are children, you see the way we treat adults, that’s not the same way, but they need special attention as compared to the adults, because they are more emotional FGD-Manager 3

Some of the Prescribers argued that, due to inadequate training, some healthcare workers don’t understand adolescents well and treat them in a dismissive manner. It was evident from the examples given that certain unusual behaviors in adolescents, which require tact, skill, and knowledge to handle, often attract unfair treatment from those who are not skilled enough to address these issues.

Sometimes I think because they don’t know how to handle some of these things and because of the way they act, they are not handled well but is it not all that bad FGD-Prescriber2

It was, however, a surprising finding from both AYAs and their guardians that prescribers were perceived as being nice, approachable, friendly, calm, and easy to relate to and open to.

Yes, the doctors are friendly, and even the last time I came the doctor I met, she was very friendly and I’m always happy if I meet friendly people I can talk. IDI-AYA 7

Yeah, the one who was in charge, she really treated her well, the psychology she used, even the way she approached us and the child, she was very calm. My wife was always happy with her, even the one who received us in the night he was also very good IDI-Guardian 8

They also had confidence in prescribers’ ability to diagnose and handle their healthcare needs, reporting good outcomes. This further fostered their initial confidence and trust, rewarding their decision based on their perceived better care in the Facility.

I have belief with this hospital. If you brought a patient here no matter how it is they will take care of him, and he will be healed. IDI- Guardian 3

One other feature of healthcare quality was patient prioritization. AYAs and their guardians value fairness in healthcare. They expect a structured, transparent system that prioritizes patients based on severity of illness rather than arbitrary decisions. The observed ineffective triage system to help prioritize patient care was a worry to them.

There should be fairness in the healthcare delivery, yes, like people who come in with emergency situations. Yes, because we were waiting to take our lab reports, and there was a girl lying there. You could see that she was shivering. But then she had to wait outside until the results were ready. So, in this case I don’t know. It’s not nice. Yeah. So, I think there should be fairness. IDI- AYA 3

And when you come here and there are plenty people and your sickness is high, you want to see them so that they will take care of you so that you will see the doctor. They will leave you to lie down and suffer. I am talking about the nurses because if you come here, it is their responsibility to take care of you first. So, if you come here and they leave you and something happen to you I will say it is their fault IDI-Guardian 4

Accessibility is a key tenet of adolescent-responsive services [4]. AYAs don’t only look for healthcare services that are accessible, but they must also be convenient. Convenience has different forms to them and includes comfort; “In the polyclinic, the doctors here, they’re very free” IDI-AYA 6, ease of access to a doctor, payment relief and modalities, and easy navigation, which to them are as important as accessibility.

I see to it that this place is better, and this place is easy to meet the doctor than when you go to other places. And there are many doctors here. So, when you are here it’s very easy to get to a doctor. When you come to this place, people are there to just direct you where to go. IDI-AYA 4

Systemic and administrative challenges

The Adolescent and Young Adults and their guardians have the notion that hospitals that they perceive as “superior” in healthcare should have structures and systems in place for effective and efficient care. They expect not just a nice edifice with modern equipment but scheme of work and protocols that help healthcare workers deliver care with high level of professionalism.

This is the major hospital in the region, and of course you should be the best. In terms of delivery, it should be very good, since it’s the face of the northern region, the face of the hospitals, not in the northern region alone, but in the whole northern sector of Ghana. IDI-AYA 7

This expectation was not met as they saw that such structures and systems were non-existent at the Polyclinic which is the face and entry point to the Tamale Teaching Hospital. The repeated network connectivity issues for the electronic health record system, lack of constant engagement with patients to explain to them what was happening during delays, no communication about the laboratory turnaround times were seen as administrative flaws of the Polyclinic.

Due to the network issue, the patients were there, no one really came out to speak to them about what was happening, to explain to them why they were waiting so long and why they were not being attended to IDI-AYA 3

Sometimes when the LHIMS [Lightwave Health Information Management System] is down like that you see that patients will just be suffering and there is no education. You know the patient does not understand what is LHIMs, I will feel you are not doing your work, meanwhile the machine is not allowing you to do your work. But I will not understand if I am not educated. IDI-Guardian 2

Almost all the staff saw network connectivity problems as a major hindrance to effective care, and that of the lack of proactive measures to address it or help in patient consultation; enshrined in administrative inertia and lack of commitment. Administratively, they also expected better organization of the care and structures to provide adequate privacy and confidentiality.

The LHIMS, if there is no network it is a major challenge because this week, I learn mostly in the mornings the network is not working, even if you are done with the labs, you can’t send the results FGD- Lab staff 2

Ineffective supervision of doctors to make them accountable to curb doctors’ lateness and/or absence from work was also a major concern from some of the AYAs and staff but the Guardians were silent on this aspect.

So, when I came to see the doctor, she said she was going to eat, I came in the morning, when she left, she never came back. So, we had to wait for the afternoon doctors to come. That was the challenge IDI-AYA 1

I think in the morning, Polyclinic is doing well. But the afternoon session is where the problem comes, in terms of waiting time because some of the doctors would most likely close before 2:00pm. And the patients that come at exactly 2:00pm will have to wait for the afternoon ones to come. So, the patients have to sit for more than an hour even after taking the vitals FGD-Lab Staff 2

Autonomy, confidentiality and privacy

Parents, guardians and community members are gatekeepers and play critical role in acceptance of services offered to AYAs, even in adolescent and Youth friendly facilities. Evidence suggest that lack of confidentiality, privacy and trust are major barriers to adolescent healthcare [1, 16, 18, 43]. The guardians and staff in this study acknowledged the critical impact of these principles on quality of care. And it was heartwarming to note that almost all guardians, except two, endorsed the need for adolescent autonomy, privacy and confidentiality in healthcare. One guardian related to it this way.

That’s the best. It is the child who is sick, you the father you don’t know what is in the body, if only the child can talk for himself, you will just sit aside and the child will talk whatever is worrying him and then if money needs to be spent that is your duty but to talk about the sickness you the father you are out of it. IDI-Guardian 3

One of the two, initially said; “that’s your father or your mother. Why don’t you want him or her to also take part or hear? What secret do you have to prevent him to hear? People have been doing that, but I don’t agree to that, no!” IDA-Guardian 8. Yet paraphrasing to help him understand the value of it as required in WHO global quality standards [46], he rescinded his initial position and said; “OK, what you have said now I understand you, especially if she is a girl, a grown up girl, there are certain things she might not like her father or mother to hear. But somebody else, especially if a doctor is asking; only as you’ve been doing, that’s your work, you have been trained for that. I heard you say it is confidential. So, I’ll just advise that it is not bad you keep it on.” IDI-Guardian 8.

What however was not explored was the type or package of health service that this endorsement is meant for. Some of the staff also related how it is impacting care. As already mentioned under the systemic challenges about the lack of structures to provide adequate privacy and possibly trust at the triage area, a female adolescent who had condom retained after sexual intercourse refused to open to the triage nurses.

Recently, a 17-year-old girl came; when she came, we were all ladies sitting at the nurses table…, We asked her why she wanted to see a doctor, she just said she wasn’t feeling well. So, we tried to inquire about what she was feeling, so she just said she wasn’t feeling well. She waited in the queue till she got into the doctor’s room…., then the doctor now called us that why didn’t we inquire from her what was wrong with her then she was now coming in late? So, we told the doctor that we had asked her twice and she just said that she wasn’t feeling well. She needed to see a doctor. Her problem was she had a condom that was slipped inside her for two days FGD-Nurse 4

The nuance on the general effect of the lack of privacy from all the nurses was almost the same and one of them summed it up this way.

At the OPD, the issue would have been the way the triage is set up…, but if there was privacy, maybe there was a bar, to prevent people from hearing, they could have opened up. FGD-Nurse 1

At the consulting rooms, doctors cannot examine Adolescent patients thoroughly due to lack of privacy and others also stated that having many people and guardians in the consulting room hinders their openness.

I also think that privacy, confidentiality; patient is in the consulting room and there are a lot of people in the consulting room, anyway, it’s a teaching center, and the patient cannot voice out the main thing. They will just be beating about the bush until someone leaves the consulting room, and they now see that it is between patient-doctor and they now voice out their problems. FGD-Prescriber 4.

This age group, some of them come with their parents. It is good to invite the child first, excluding the parent because some of them have been put under pressure, questions and other things, so when they come and the parent enters the consulting room with them, they will never open. FGD-Prescriber 3.

One of the AYAs was emphatic about the importance of these crucial practice principles. She came with vaginal infection and the issues discussed above played.

Like today when I came, I met two guys at the nurses’ station…, And then when they started asking me questions even though I gave them some reasons for coming, but due to certain things I couldn’t answer them and then they later realized that I was kind of shy. It was opened. Even if you come to health sector like this, If you go inside the consulting room and then you meet a doctor and then there is a second party in, it is going to be difficult for you to say it IDI-AYA 10.

More importantly, the Adolescent and Young Adults saw healthcare services that are organized to provide autonomy, confidentiality and privacy as the preferred approach and also welcomed consultations that will explore every aspect of their health. However, one of them saw friends and colleagues as trusted people to discuss confidential matters about her life than doctors.

Young ladies are underage and mostly wouldn’t want their parents to know certain things about their reproductive health. So. If they are given the chance to talk to their doctor in the absence of their parents, I think it would be great. Yes, it would help, and it should be done.” IDI-AYA 12

Adolescent health conditions and needs

The health conditions that made them visit the Tamale Teaching Hospital Polyclinic were curative in nature; and included communicable and non-communicable diseases. The other predominant health needs of AYAs that participants identified were sexual and reproductive health needs. Bullying and substance use were mentioned as the other issues that affect AYAs health. Anticipatory guidance was a much-needed service to AYAs according to their guardians.

Sexual and reproductive

“And most of these things we the ladies when you’re growing up, we are getting changes in your body, like you don’t know who to talk to.” IDI-AYA 8.

Infection-related

“The first one was malaria. I was expecting malaria. So, I came to the hospital for confirmation.” IDI-AYA 3.

Substance Use

“The substance abuse, it’s something serious, especially we those handling the substance at the Pharmacy. Most of them don’t come to just talk to you about being addicted to a particular substance, they don’t come to tell you that. They don’t say it, at the end of the day they want to find out about accessibility to that substance. They will ask you that if I pay for this, will you give me?” FGD-Pharmacy staff.

Bullying

“Most often they come with the hysteria nature because of bullying by their seniors in school. So, they tend to intensify it so that it will look like something big. Because I have encountered several students in that nature, they are being bullied by their seniors.” FGD-Prescriber 3.

The AYAs and Guardians in this study value anticipatory guidance and the psychosocial history consultation techniques (HEEADSSS- Home environment, Education and Employment, Eating and Exercise, Peer-related Activities, Drugs, alcohol, tobacco, Sex and Sexuality, Suicide, depression and other mental related issues and Safety from injury, violence, abuse) intended to help unearth problems that are not normally talked about in tradition consultation style as a useful tool. We enquired about their opinions on it, and they all accepted it as a necessary tool. One guardian didn’t mince words and said, “I even love it that way” IDI-Guardian 1.

I will say that this your initiative is good if you guys are able to implement it and I think it is going to help many young people IDI-AYA 6

And then the most important thing in life you doctors should advise we parents, if you want your kids to be healthy, unless you give them the food that the kids need. Your side is to advise us how to make them somebody tomorrow IDI- Guardian 3.

It was surprising that none of the AYAs came because of psychosocial issues, yet one of them had ever been addicted to pornography and masturbation and needed help but never knew there was such help in the hospital. This might be due to lack of knowledge of existing services due to low health literacy [16, 26]. On the other hand, such consultation opportunities don’t exist in mainstream clinical service delivery so that could have been the other limitation.

Participants perspectives on improvement

This theme was developed from codes from participants’ suggestions on general improvement and solutions to existing problems and what redesign and further restructuring should incorporate as well as drawing useful insights from concepts and theories on patient engagement in health care planning, design and implementation [27–32, 48, 49].

AYAs and their guardians treasure healthcare providers who are friendly, approachable, empathetic, patient and actively listen to the concerns of young people. Healthcare providers with these qualities foster greater trust and openness among AYAs and this was evident in this study between doctors and AYAs. Also, the staff’s views were that adolescent-responsive services are sine qua non for quality care for this population. Restructuring mainstream services to improve quality and make it adolescent responsive featured in what should be done to make healthcare more responsive, accessible and appropriate for adolescents.

I think patient education, yes, so in the sense that, I’m using today as an example; due to the network issue, the patients were there, no one really came out to speak to them. So, if there’s one thing I will change that will be It. So instead of just allowing them to sit there and think maybe you don’t care, you can explain to them what’s happening……” “I think there should be fairness in the healthcare delivery. Yeah, so I think there should be fairness. And the attitude towards the work is very important. IDI- AYA 3

Especially the nurses they should be very friendly because they are the people we meet first, if I come here and I’m seriously sick, even the introduction alone can either make me sicker or a bit well. So if I come and I meet you and you frown your face and I’m talking to you and you are shouting at me, I even get more sick, but if I come and you are happy, you try to relate with me well and make me feel comfortable and encourage me with that, I’ll be able to get back on my feet very fast. IDI-AYA 7

The supervision of the workers should be strong IDI-AYA 8.

What stood out among the guardians’ views on improvement was care should not only be about giving medications but should include anticipatory guidance.

Everyone wants better children. They meet people who give them good advice and some bad advice. They get bad advice from their friends in school so if doctors have time to counsel them, they will understand clearly things that are helpful and things that will not help them. IDI-Guardian 4

Other views were that getting a dedicated clinic and staff as a stand-alone adolescent services/Clinic will greatly improve their care.

I think we should get a space that is separated from the public eye where they can come confidently to get their services. We should have dedicated, if it’s possible, dedicated physicians or nurses, so that in case young people at that ages come we should be able to take care of them faster FGD-Nurse 3

Others indicated that the curricula for training healthcare workers should include modules that make healthcare workers more capable and skillful to take care of adolescents. And others also called for in-service training.

At policy level, we should start looking at how they can incorporate that into the training institutions, so that going forward we also understand them before we come out to practice. So that we can do the postgraduate things to deepen the knowledge. FGD-Prescriber 1

We also have to do some form of in-service training once a while to also educate the staff about how to handle this age group. FGD-Prescriber 2

What was strikingly missing was that, aside from curative and anticipatory guidance, AYAs and their guardians were silent on the non-existent services; especially the widely acknowledged reproductive health needs of these populations as mentioned by AYAs themselves, some guardians and most staff. Staff as well did not fully articulate all service packages or components that needed to be added to existing services to make the services comprehensive, holistic and well-integrated.

Discussion

We found in this study that AYAs gravitate towards high quality health services and place a high premium on positive healthcare worker-AYA relationships and interactions. They also value comfort in healthcare and services that are convenient and easy to navigate. Facility level barriers, such as negative staff attitude, inadequate training of healthcare workers, ineffective supervision and lack of communication during delays are constraints that affect quality clinical care. Psychosocial assessment and services that provide privacy and confidentiality to AYAs and give young adults autonomy were embraced by all participants and they all suggested that more concerted efforts need to be made to address barriers and improve care.

The findings in this study agrees with the WHO assertion that adolescents are least served well by existing healthcare systems in many parts of the world [1]. Although, there is increasing attention given to Adolescent healthcare with development of National Adolescent Health Policy and Strategies, the existence of such policies in Ghana proved insufficient for tangible gains as seen in this study [7, 26]. Agblevor et al. also reported that Ghana’s Adolescent Healthcare is beset with lack of political will for national implementation drive [7]. Which could explain the poor quality of care findings in this study almost ten years after such policies were rolled out in Ghana. Poor utilization of health services was reported in the situational analysis in the Ghana National Adolescent Health Service Policy and Strategy, although the said service was not mentioned specifically [26]. Kyilleh et al. [16] at West Gonja in Northern Region and Hagan et al. [17] in Kumasi, Ashanti region of Ghana both reported low utilisation of sexual and reproductive health services.

In this study, reproductive and sexual health was identified as important health needs of adolescents and young adults, yet none of the AYAs recommended that it should be added to the existing package of services and it is difficult to extrapolate a reason for it. Apart from this, the other findings in this study revealed that AYAs positively gravitate towards high quality clinical care. Hostile adults whose attitude make healthcare services unfriendly to adolescents was also reported in systematic review by Jonas et al. on studies done in 17 Sub-Saharan African countries between 1990 and 2015 [5]. The same pattern was reported by Mbalinda et al. in Uganda [24], and Kyilleh et al. [16] and Hagan et al. [17] in Northern and Ashanti regions of Ghana respectively. Just as found in this study, they also reported that repulsive healthcare workers’ behavior creates fear in Adolescents and made these healthcare workers unapproachable.

This study found that adolescents place much premium on Autonomy, Privacy and confidentiality. Oppong-Odiseng et al. [50] had similar findings and also observed that AYAs did not trust school clinics (because they were near to where familiar people were found, and also due to proximity to their familiar environment) as safe enough to provide them adequate privacy and confidentiality. The need for safe environments that provide privacy and confidentiality was seen in other studies to be so crucial in our Ghanaian context for uptake of sexual and reproductive health services [17, 18, 41]. Although in this study, that was not specifically explored, the need to provide care that ensures AYAs have adequate privacy and confidentiality, and that it gives them autonomy was evident. This study also shed light on the readiness of both AYAs and Guardians to embrace psychosocial history assessment that can help unearth health issues in adolescents early. This area was not yet explored by studies done in Ghana. This study, to the best of our knowledge, is the first clinical service study to employ patient engagement concepts and theories to inform reforms and improvement in clinical care to adolescents in Ghana.

The authors therefore identified four broad areas for pragmatic action for improvement in Adolescent health services in the study facility, Northern Ghana and the country as a whole: (1) restructuring mainstream services to become more responsive to adolescent healthcare needs. (2) Strategies to improve health literacy on adolescent health concepts and development among AYAs, guardians and community, (3) Establishment and linkage to specialized services for adolescents and (4) Incorporating Adolescent Health into existing curricula for training. The schema for this concept is attached as supplement.

Seeing the disparities in the implementation of various services for adolescents, WHO is now advocating for going “beyond single problem thinking” as they noticed that out of 109 countries reviewed that gave attention to adolescent health, three-quarters focused only on sexual and reproductive health. WHO again emphasized in this document that risk reduction interventions for adolescents for various health problems should be tackled jointly because they share common characteristics or have similar underpinnings [1].

We are of the view that restructuring mainstream services (routine clinical services) to become adolescent-friendly and more responsive is more sustainable than stand-alone services due to human resources, infrastructural and financial constraints. The restructuring will include organizing care that provides comfort, and confidentiality; Care that is appropriate and easily accessible at an affordable cost. The views of patients and the community must also be incorporated to make it culturally appropriate, convenient, acceptable. This study revealed lapses that should be looked out for and addressed in any facility. Private consultation alone with Young Adults 18years and above should be instituted in routine care.

Regular In-service training using national and WHO documents and tools to build requisite knowledge, skill and improve communication among healthcare workers taking care of adolescents in primary care is crucial and can address the infractions observed in this study [51–53]. This training from the self-determination theory perspective will equip staff with knowledge and skills to become more confident and tactful in delivery of services to AYAs. It is expected to promote willingness to offer adolescent-responsive services and thus be seen as autonomous support. Also, it will increase their competencies for improved Adolescent-staff relatedness. In this study, the staff requested for regular in-service training to be done and it is expected that it will lead to sustained intrinsic motivation for improved care if done. There is evidence that supports this expectation as human resource management strategies suggest sustained employee motivation for improved outcomes from this perspective [54–57].

This study focused more on the clinical aspect of care within the study facility, but other aspects of healthcare needs that the restructuring should take into consideration and integrate into mainstream care are sexual and reproductive health service units, mental health units, adolescent nutrition and outreach to schools. Annual school health outreaches at school clinics can be used to address their health risks [3].

Also, efforts must be made to involve parents and community members as they serve as gatekeepers and can also contribute greatly to social behaviour change and implementation of healthcare interventions [1, 19–22]. Neurodevelopmental psychology evidence explains the heightened risky behaviours such as risky driving, binge drinking, substance use, and unsafe sex during adolescence and this evidence must be used to plan interventions outside the hospitals. What will equip AYAs themselves, guardians and community members is a good understanding of how the imbalance in the reward-seeking regions and the cognitive control network regions of the brain of adolescents’ impact adolescent behaviour and decision-making.

It is known that the unique social influence in adolescents is not found in children and adults in empirical developmental studies [58]. The social motivation model posits that valuable social goals increase AYA’s social motivation to demonstrate or conform to peer risky behaviour to attain them. It is crucial to understand what these social goals are and what they are not to enable less risky or meaningful roles or responsibilities to be planned to replace them where possible. The reward sensitivity model suggests that “arousal leads to altered reward processing, making risk-taking more appealing” [59]. The presence of peers brings this arousal and signaling for rewards, and interventions to model good behaviour and decision-making should among other things include restricting AYAs from risky gathering or social or media programmes. The distraction model reveals the need for training in mindfulness and meditation to develop desirable behaviour as these have been found to be helpful in reducing and improving depression symptoms among AYAs [60] Youth clubs are ideal avenues for modeling good behavior and can employ role plays to promote risk aversion and meaningful role interventions. Also, teachers, social media, mass media, cell phones all impact adolescents’ lives and health literacy strategies ought to strongly consider using these avenues to reach adolescents and young adults. Peer Education using expert patient education models is a strong incentive for peers to influence other AYAs positively. The current Ghanaian health system lacks structures and programmes that leverages these opportunities for adolescent health literacy, and this must be looked at.

The other gap in service delivery is around healthcare transition. Adolescents with chronic diseases such as Type I diabetes, Asthma, Sickle Cell disease, Seizure disorder, and HIV/AIDS usually get lost to care after Paediatric care. Paediatrics and Child health services typically end at age 12 in Ghana. Although Adolescents with these chronic diseases are usually seen by Paediatrics until 18 years old, National Health Insurance reimbursement becomes an issue, and the lack of a structured transition plan makes their health outcomes decline afterwards. Staff at adult clinics are typically unfriendly to adolescents [5, 24]. It is therefore imperative to have a well-structured transition of care from Paediatric Chronic care clinics to adolescent-oriented or specialist clinics either manned by Physicians with training in adolescent healthcare or adolescent medicine physician specialists. The integration of services talked about earlier must also occur in these clinics where all their needs are collaboratively addressed.

The current late training approach whereby Adolescent Medicine which gives much attention to adolescent healthcare is reserved for fellowship training arguably contributes greatly to why the existing healthcare system serves adolescents least well [61, 62]. As one of the participants aptly put it above; a young population like Ghana’s should position its healthcare system properly to take good care of its future workforce which constitutes more than half of its population. This view point is strongly endorsed by WHO [53] and Kokotailo et al. [62]. Unfortunately, this is not the case in Ghana and many African countries. It is expedient that pre-service training for all healthcare workers should be robust enough in adolescent health to make healthcare workers competent and skillful. Although specialized care clinicians are needed for complex stand-alone practice settings, in our view what best suits our healthcare system is better pre-service training in adolescent health. Therefore, we propose a model for training and integration of services where every qualified healthcare worker gains the requisite knowledge, skill and attitude for quality adolescent healthcare services. Postgraduate education is necessary just as in other disciplines but should not be the only form of training, often awaited, and in many places unavailable.

Strengths and limitations

The procedure employed to recruit and interview participants and analyze the data ensured across service points inclusion and all clinical service aspects assessment both from patients, guardians and staff members. Rigor and quality measures were employed in designing interview guide, choosing analytic direction and analysis and manuscript write up. The limitations of the study are potential social desirability bias and inability to give participants opportunity to validate the themes generated.

Conclusion

AYA and guardians want convenient, easily accessible and high-quality care, delivered by a friendly and trusted team, which views the healthcare workers also endorsed. There is a need for training of healthcare staff in adolescent friendly and responsive services, as well as facility level reforms and restructuring of mainstream services to make them more appropriate and responsive to the needs of this population.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

NYU

New York University

NY

New York

U.S

United States

USA

United States of America

AYA

Adolescent and Young Adult

WHO

World Health Organisation

OPD

Outpatient Department

IDI

In-depth Interviews

FGD

Focused Group Discussion

LHIMS

Lightwave Health Information Management System

HEEADSSS

Home environment, Education and Employment, Eating and Exercise, Peer-related Activities, Drugs, alcohol, tobacco, Sex and Sexuality, Suicide, depression and other mental related issues and Safety from injury, violence, abuse

HIV/AIDS

Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome

Author contributions

Conceptualization: JAA, AAM, SRI, Interview Guide: JAA, SRI, MAB, Data Curation: JAA, OS, AMA, MHK, Formal analysis-JAA, STE. DSA, Methodology JAA, AAM. Supervision-JAA, AAM, Writing original draft-JAA, Writing, Review and Editing-JAA, AAM, STE, DSA, MAB.

Funding

Funding for this study was provided by a grant from University of Louisville and AMPATH consortium and Marie A. Brault’s time was partially funded through NIH award K01TW011480.

Data availability

The datasets and materials used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval and consent to participate

The study was approved by the Committee for Human Research Publication and Ethics of Kwame Nkrumah University of Science and Technology at Kumasi (CHRPE./AP /528/24). The study was carried out in accordance with ethical standards on human subjects’ research set out in the Helsinki’s Declaration. Witten informed consent was obtained from all participants of the study. Minors who took part in the study first assented to participate and their legal guardians gave written informed consent before they were interviewed.

Consent for publication

The authors received consent for publication of the study from participants.

Competing interests

The authors declare no competing interests.