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Table 5 Main findings of evaluations (N=18)

From: Measuring adolescent friendly health services in India: A scoping review of evaluations

  Findings from the evaluations of:
ID Design Implementation Outputs (quality and coverage) Health behaviour outcomes Health outcomes Comments
Eg. Project goal
Project objectives
Framework of design
Key approaches and strategies
Rationale or basis
Key actors
Implementation plan
Activities undertaken
Key influences
Monitoring plan
Use of monitoring information
Mid-course adaptations/changes
Pre-inputs: Training material, training of trainers, clinical monitoring (CM), CM training, supportive supervision (SS) material, SS training
Inputs: Training of health service providers, making facilities AFHS, problem solving, SS
Outputs: Improved quality of services
Outcomes: Improved use of services
Effect on adolescent behaviour (sexual behaviour, condom/contraceptive use behaviour/health seeking behaviour) Eg. nutritional status, early pregnancy and pregnancy related mortality and morbidity, STIs and HIV Other evaluation dimensions: community support and adolescent demand, planning and management, institutionalisation, cost
A     Better Life Options participants were more likely to have received antenatal care during pregnancy (91% vs. 64%), received tetanus toxoid immunization during pregnancy (91% vs. 62), delivered in health facility (50% vs. 36%), received post-natal care (57% vs. 39%), and currently be using contraception (36% vs. 27%)
Children of participants 12 months or older more likely to have received complete primary immunizations (63% vs. 32%)
Better Life Options participants were more likely to report having given child oral rehydration salts during diarrhoea (42% vs. 12%)
Better Life Options participants had lower mean number of children (1.73 vs. 1.98)
Better Life Options participants had lower rates of child deaths (RR=0.88)
Other social outcomes including age at marriage, level of education completed, literacy were also were also evaluated
B   Intervention was feasible (focus on general adolescent health very effective; programme faced little resistance from parents, programme implementers, schools)   Statistically significant (p<0.01) percent change (%Δ) in knowledge of modern methods of contraception (male/female sterilization 37.6%Δ, condoms 34.6%Δ. intrauterine device 25.0%Δ, desire for less than 3 children 13.1%Δ, knowledge about need for 3 antenatal care checkups%Δ
Statistically significant (p<0.01) increases in knowledge for each of 4 modes of HIV transmission (sharing needles 39.8%Δ, unprotected sex 30.1%Δ, mother to child transmission 32.3%Δ, blood transfusion with infected blood 35.0)%Δ
Statistically significant (p<0.01) reduction in proportion of participants with anemia (Hemoglobin<10 grams) from 86% to 20% among 10-14 years and 86% to 36% among 15-19 years
Mean Hemoglobin level improved (9.0 grams/dL to 11.1 grams/dL in 10-14 years, 9.0 grams/dL to 10.7 grams/dL in 15-19 years)
C   Evaluation identified programme implementation, noting that ARSH-related supplies were found to be available, but not uniformly being distributed to adolescents Difference in quality scores between ARSH and other clinics for each standard (statistical significance is not reported):
1. Health facilities provide the specific package of health services that adolescents need: 65% in ARSH versus 22% in other
2. Health facilities deliver effective services to adolescents: 78% versus 39%
3. Adolescents find the environment at health facilities conducive to seeking treatment: 86% versus 33%
4. Service providers are sensitive to adolescent needs and are motivated to work with them: 94% versus 59%
5. An enabling environment for adolescents to seek services exists in community: 63% versus 12%
6. Adolescents are well informed about health services: 44% versus 1%
7. Management systems are in place to improve/sustain the quality of health services: 45% versus 13%
No apparent difference in performances of PHCs vs. SCs
Most intervention sites progressing well towards meeting the standards
D    Awareness of AFHS 8x higher in intervention area than comparison villages (68% versus 8%)°
Use of government health facilities was higher in intervention than comparison villages (55% versus37%)°
Denial of contraceptive services was perceived by majority of adolescents in both intervention and comparison villages
More adolescents in intervention villages understood explanations of health problems than in comparison (83% versus 42%)°
No major differences between groups in acceptability and availability of condoms
E   Some centres were non-functional due to transfer of MO who was oriented about centre and lack of human resources
Major challenges to monitoring exist
Utilization data (average number of adolescent patients/month) showed minimal utilization. Where records available, average 250 adolescent clients/month.
Focus groups revealed that adolescent boys and girls are generally unaware of ARSH centres and/or services. Use of services related to RSH problems is limited due to lack of awareness and knowledge
   Quality of health services based on provider report, not direct observation, and scoring performed by evaluation team
F   Only 1 facility (SDH) was “designated” AFHS at time of assessment Proportion of 7 standards of ASRH services implemented at each facility ranged from 19% to 42%
Single facility that had been designated AFHS (SDH in Karjat) scored 31%
Most broadly implemented standard (57% of facilities met standard) was standard 4: “Service providers are sensitive to adolescent needs and motivated to work with them.”
Least implemented standard (1% of facilities met standard) was standard 6 (“Adolescents are well-informed about health services.”)
   Positive feasibility of using quality assessment tools
Comment that focus group discussions are needed to gather better inputs for standards V and VI
G   83% of clinics had been functional for less than one year 42% maintained audio and visual privacy
58% had displayed boards and 25% had adequate signage
No ARSH facilities were found to have at least 100 condoms or at least 10 cycles of Oral Contraceptive Pills available, 83% had Emergency Contraceptive Pills available
67% had access to ARSH guidelines
Utilization of services low: 14.5% of adolescents interviewed had used clinic in past 6 months)
Few providers felt adequately trained
H    53,137 adolescents (40% male, 60% female) accessed services provided by 73 clinics
-Scope of services included contraceptive choices, handling concerns related to menstruation and gender-based violence, improving life skills, providing antenatal services, treatment of Reproductive Tract Infections/Sexually Transmitted Infections
Access and quality of services were quite limited (report did not provide data to support this)
I    Adolescent health care available in 85.4% of SCs in 7 different states
School health programmes in 77% of PHCs and related facilities in different states
ASHA participation in sensitizing adolescent girls was found to be unsatisfactory (Data not provided to support this)
J     If comprehensive intervention is discontinued, there is an initial decline in contraceptive use in both groups after activities end, then stabilizes at higher level than pre-intervention
Longer duration of comprehensive intervention was associated with greater increase in contraceptive use (a more modest effect demonstrated over shorter (2-3years) period of time
Joint exposure of young married couples to PRACHAR communications is more effective than exposure to men alone
PRACHAR interventions led to increased contraceptive use among all socioeconomic and education groups, but highest impact in most disadvantaged
K    AWW and ASHA stakeholders have more knowledge about health concerns/programnes meant for adolescents than did teacher and Panchayati Raj Institution members
Quality of services most adequate in relation to facility measure (separate room, exam table, display boards, records/registers, weighing scale) and supply measures (condoms, Oral Contraceptive Pills, Emergency Contraception, etc.)
Information Education Communication materials and outreach services, co-curricular education activities are lacking
Low SRH knowledge in adolescent community   
L   Scale-up included changes based on findings from evaluation of pilot intervention, including the addition of new service delivery points, shift in monitoring responsibilities, improvements in efficiency of services   Improved attitudes and behaviours related to reproductive and sexual health including decrease on preference for male child from 39.9% to 25.7% (p<0.01), increased awareness of legal minimum age of marriage for girls from 68.2% to 85.4% (p<0.01), and increased use of sanitary pads increased from 30.6% to 52.7% (p<0.01)   
M    Majority (90%) of clients aware that YFHS provide services to young men and women separately on specific day/time
66% of clients visited YFHS to seek treatment for 3 key problems (menstruation, general illness, swelling/itching of genitals)
Privacy not consistently ensured according to clients
O    32% of interviewed clients reported satisfaction with AFHS
Satisfaction was positively associated with female gender, higher education status, Hindu religion
Multivariate model showed greater satisfaction associated with parental support (odds ratio = 4.4), much lower satisfaction associated with fear of privacy disclosure to parents (odds ration = 0.08) – this factor was more important than parental attitudes
Client satisfaction did not vary by appropriateness of time given by provider, clients’ belief regarding confidentiality of information, provision of information request
P    Raw quality scores showed steady improvement with average score of 83% across all 8 health facilities in 5th year of evaluation and 79% across 12 sub-centres.
No statistical analysis of change in scores over time.
Persistently low performance of standard II (effectiveness of health facilities, including equipment and supplies)
Q Situation analysis informed development of the following interventions as a block action plan:
(1) Refresher trainings for providers (2) Linkages with schools ad community organizations (3) Standard operating procedures and management information systems (4) Demand generation through collaboration with education department (5) Mobile helpline service (6) Quality assessment programme evaluation at the end of each year to be performed by external evaluators-
Feasibility assessment of block action plan found that: (1) Adolescents will not come to clinic on a particular ARSH day, so clinic schedule shifted to “anytime approach” in the block (2) Medical camps for adolescents helped strengthen linkages with schools/colleges, parents, and teachers and have facilitated demand generated (3) Linkages with NGOs helped created awareness of ARSH services (4) Proactive involvement of education system and clear guidelines are essential (5) Referrals within the block are not helpful since quality at sub-district hospitals are not superior
(6) Interventions with limited scope were peer volunteers, mobile line service, and an adolescent health committee
(7) Clear cut guidelines on ARSH exist from Government of India, but no departments except health sector have specific policies for roles and responsibilities related to adolescents
Findings of quality assessment programme
reported in separate evaluation document (43)
R    Most health care providers had undergone some training or sensitisation on SRH issues relevant to adolescents – some within context of general training and others through special training programmes
ASHA and ANM training more often focused on “safer issues” like nutrition and menstrual hygiene while counsellors and MOs also received training on sexual relations, infection, pregnancy, and abortion.
Fewer training experiences with privacy, confidentiality, non-judgemental interaction, promotion of informed choice, and communication skills
“Cascade approach” to training reaches large numbers, but not successful in building capacity on intractable aspects of service provision like building communication skills and overcoming discomfort in talking about SRH issues
Gendered responses regarding what information adolescents should receive, most believed that information provision to girls should be mothers and female providers like ASHAs and ANMs while boys should get information from other males (MOs, counsellors, etc.)
Providers generally observe that adolescents and youth do not access SRHS available at community level or at AFHCs at facility levels
Based on exit interviews and mystery clients, suitability of services was mixed with most commonly cited complaint being lack of privacy
<50% of surveyed men and <66% of surveyed women who experienced an SRH problem had sought advice and/or treatment, fewer (33%) for mental health concerns. Most sought treatment from medical officers in government or private facilities.
Adolescents reported limited interaction with frontline and community HCPs (ANMs, ASHAs, and AWWs)
Awareness of AFHCs was low among adolescents (5% of young men and 8% of young women surveyed were aware of services), <1% had ever sought services
  Report also summarizes the perceived health problems among adolescents surveyed as well as their preferences about health care providers and facilities
S    Data on health facilities providing ARSH services is sparse and only covers public facilities.
There has been insufficient training of providers of these services.
Quality of services is poor due to lack of manpower, lack of trained manpower, space constraints, poor community participation, time constraints.
Knowledge of medical care providers and majority of paramedical care providers was sufficient, however majority of paramedics reported lack of comfort in communicating with adolescent clients.
Facility surveys reveal lack of optimum information education communication/Behaviour change communication material, inadequate space for privacy, and long patient queues. 77% of facilities had adequate stock of key supplies.
Adolescent exit interviews reiterated above issues and also reported long waiting times, stigma of being seen in facility, inappropriate clinic hours/days, and low understanding by family and community members for SRH needs
Low awareness of ARHS problems and availability of service among adolescents in community