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Chalmers et al. (2006) define the programmatic context as the context in which responses to young people’s sexual health needs take place. In many developing countries, adolescents obtain SRH services in health facilities where services are primarily designed for adults, particularly adult women (Laski and Wong, 2010). Although research has indicated that most adolescents do not seek health services for sexual and reproductive health concerns (Biddlecom et al., 2007), evidence also indicates that sexually active adolescents do utilize health services to some extent (Laski and Wong, 2010; Meuwissen et al., 2006). This section will discuss (perceived) barriers and facilitators to adolescents’ utilization of SRH and related services. While a range of factors are discussed in the literature, the programmatic factors below are broadly categorised as relating to matters of accessibility and acceptability, which are categories used by the WHO and others (e.g. Tylee et al., 2007; Pearson and Makadzange, 2008; Berhane et al., 2005; Barker et al., 2005).

Accessibility

According to Maxwell (1992), accessibility of health care can be described in terms of whether “people are able to get treatment/services when they need it” and include factor such as “distance, ability to pay, and wait time” (p.171). Some studies (e.g. Berhane et al., 2005; Booth et al., 2004) capture accessibility as an aggregate measure whereas others (e.g.

Biddlecom et al., 2007; Miles et al., 2001; Atuyambe et al., 2009) disaggregate the measure to include the factors discussed by Maxwell, in addition to other factors, such as knowledge of service. A cross-sectional survey using self-administered questionnaires was used to assess adolescents’ health service utilization patterns, their attitudes and preferences towards existing health services in Ethiopia. The authors reported that one-third of 10-24 year old male and female secondary school students (N=2,647) reported that existing health services were inaccessible (Berhane et al., 2005). Participants were reporting on access to service utilization for RH and other illnesses they had experienced in the last three months. Nonetheless, findings pertaining to adolescents’ actual or perceived access to SRH services have been mixed.

Knowledge of service

Knowledge about places for getting SRH-related services is also used as an indicator of access and a contextual factor, because lack of knowledge may be due to lack of services or lack of marketing about available services (Char et al., 2011). Biddlecom et al. (2007) found that significant proportions (see

) of adolescents ages 12-19 in some of the countries in their study did not know where to go to obtain contraceptive methods or STI diagnosis and treatment. However, most of the adolescents did not report having an STI or STI symptoms. The study relied on adolescents’

self-report of STI and STI symptoms, therefore, there is the potential for under-reporting of both STI symptoms and treatment-seeking (Fortenberry, 2009).

Table 2-2 Percentage of 12-19 year olds knowledgeable about where to go or how to get there to obtain contraceptive or STI diagnosis and treatment among those who had sex in the last 12 months in 4 African countries in 2004

(Source: Biddlecom et al., 2007)

Booth et al. (2004) researched access to health care among 12-17 year olds in New South Wales, Australia. The authors found that across all groups, many adolescents were unaware of the range of available services from family practitioners and the range of skills that providers may have that could be relevant to their needs, which inhibited many adolescents from seeking health services. Interestingly, Booth et al. (2004) reported that out-of-school adolescents were far more likely to be aware of available services, especially youth health services. The authors attributed this to out-of-school adolescents being forced into health care by the Juvenile Justice (i.e. forced help-seeking).

Distance and transportation

The location of health services and the ability to reach them has also been recognized to affect adolescents’ access to SRH services (Miles et al., 2001; Kiapi-Iwa and Hart, 2004;

Atuyambe et al., 2009). Miles et al. (2001) conducted 12 focus groups with young men and women aged 15-25 in three rural villages in Gambia to understand the social processes that inform young people’s health seeking behaviours for STI advice and treatment. The authors found that distance from the health centre and the lack of transportation to access STI advice and treatment was a recurrent barrier reported among young people. Similarly, Kiapi-Iwa and Hart (2004) found that distance was a barrier to obtaining condoms among adolescents in Uganda. However, distance and transportation was not always perceived or experienced as barriers to access (e.g. Biddlecom et al., 2007; Kumi-Kyreme et al., 2007). The majority of adolescents in Biddlecom et al. (2007) study thought they would be able to easily reach a clinic or hospital, especially those in Uganda (82% - 86%). The difference between these research findings could be a result of how the questions were asked, participants’ place of residence (i.e. urban/rural), and availability of health facilities. Considering the network of public health facilities in Grenada (Figure 1-6), exploring whether distance and transportation affects ASRH behaviour can contribute to better understanding adolescent help-seeking in the Grenada.

Opening hours and wait times

Opening hours and wait times have also been reported as programmatic factors that hinder utilization among adolescents for SRH concerns. Among adolescents in Zimbabwe, Langhaug et al. (2003) found that clinics not being open during out of school hours hindered utilization of SRH services. In Berhane et al.’ study (2005), the majority of respondents (70.1%) preferred designated service hours for adolescents (Berhane et al., 2005). However, among Australian adolescents, Booth et al. (2004) found that opening hours and wait times were less

salient barriers to utilizing health services. The authors argue that these are likely to become more salient if adolescents’ utilization of health services increased (Booth et al., 2004).

Cost of service

Another factor related to accessibility of services for adolescent populations is that of cost. Cost of transportation due to distance, and financial cost of diagnosis and treatment are two examples; social cost was discussed in section 2.4.1. High reproductive health service fees (Berhane et al., 2005) and high cost of purchasing condoms at the clinic (Kaipi-Iwa and Hart, 2004) were reported as preventing access to health services and utilization of condoms.

According to Kaipi-Iwa and Hart (2004), an 18 year old male participant in Adjumani district, Uganda stated, “In our locality condoms are not free of charge and therefore having no money means sex without condoms” (Kiapi-Iwa and Hart, 2004 p.344). Although, Biddlecom et al.

(2007) found that between 60% and 86% of adolescents in their survey across four African countries felt that they would be able to pay for contraceptives and STI treatment, adolescents held the least favourable view regarding ability to pay for services.

Some studies (Meuwissen et al., 2006; Berhane et al., 2005) indicate that health services available to adolescents for free or at a reduced cost can increase utilization. For example, Meuwissen et al. (2006) reported that a voucher program offering free SRH services to low income female adolescents in Nicaragua has substantially increased the use of primary care clinics for contraceptives, STI and reproductive tract infections (RTIs), advice and counselling, and antenatal check-ups (Meuwissen et al., 2006). Interestingly, nearly half of the sexually active girls who were neither pregnant or mothers and had not previously used contraceptives had redeemed their voucher. In contrast, Meekers et al. (2001) found that among in and out-of-school adolescents in Botswana, only out-out-of-school boys were satisfied and willing to access free condoms from public sector providers. These mixed findings suggest that free services may not be sufficient to improve service utilization for all groups of adolescents.

However, some adolescents do use alternative helpers when cost is a barrier to utilize Western health services (Miles et al., 2001; Atuyambe et al., 2009). For example, Miles et al. (2001) reported that female adolescents utilized traditional medical services for STIs, despite costing significantly higher than attending the health centre, because they were able to pay by exchanging goods for services. In contrast, Atuyambe et al. (2009) reported that pregnant adolescents were able to pay traditional birth attendants at a later date. The relevance of

financial cost in the Grenada context will be useful to explore, considering adolescents’

preference for private providers and data showing that adolescent comprise one of the largest subgroup affected by poverty in Grenada (Table 1-1).

Acceptability of services

According to Maxwell (1992), acceptability of services can be described as “how humanely and considerately the treatment/service is delivered” (p.171). Literature on the acceptability of SRH services for adolescents indicate that there is a lack of specialized SRH services for adolescents (Tengia-Kessy and Kamugisha, 2006) and that specialized services mostly address the unhealthy consequences of unprotected sexual activity, although the majority of adolescents in most parts of the world need mainly SRH information and counselling (Hughes and McCauley, 1998). The literature further indicates that the factors that inhibit existing SRH information and services may be inadvertent and not deliberate (Senderowitz, 1999). Similarly to research on accessibility, acceptability is discussed in the literature as both aggregate and disaggregate measures. As an aggregate measure, Berhane et al.(2005) found that almost two-third of adolescents (students) in Ethiopia reported RH services as being unacceptable. As a disaggregate measure, other researchers discuss acceptability in terms of staffs’ attitude and being able to meet adolescents’ needs, and issues of confidentiality and privacy.

Attitude and behaviour of service providers

The lack of service providers, including receptionists who understand adolescents, as well as being sensitive to their needs and realities is reported as affecting adolescent help-seeking behaviour (Berhane et al., 2005; Atuyambe et al., 2009; Langhaug et al., 2003;

Meekers et al., 2001). This has been reported extensively across Africa in both quantitative and qualitative studies. For example, 36% of high school students in Ethiopia perceived health providers as ‘judgemental and unfriendly’, which inhibited health service utilization (Berhane et al., 2005). Similarly, adolescents experiencing teenage pregnancy in Uganda reported that

“‘don’t care’ attitude and rudeness and abusive behaviour of some health workers”

discouraged them from seeking antenatal and delivery services (Atuyambe et al., 2009 p.790).

Additionally, Langhaug et al. (2003) interviewed both nurses and adolescents who attested to nurses “shouting at, mocking, labelling and judging young people” seeking RH information and services for prevention or treatment (Langhaug et al., 2003 p.151).

Adolescents’ perceptions and/or experiences also affect the source of help from which they chose to cope with their SRH concerns. For example, Meekers et al. (2001) reported that private sector providers were more willing to provide services to adolescents compared to public sector providers, but perceived that drug shop owners sometimes gave adolescents questioning looks when purchasing condoms. This might help to explain adolescents’

preference for obtaining condoms from peers (Meekers et al., 2001). However, not all adolescents perceived negative provider attitude and behaviour. Biddlecom et al. (2007) reported that between 75% and 95% of the sexually active adolescents in the four African countries examined reported they were likely to be treated with respect in clinics and hospitals.

Maintaining confidentiality and privacy

Confidentiality and privacy are often used interchangeably in the literature. However, in discussing adolescents’ need for health care privacy, Britto et al. (2010) framed privacy as a multi-dimensional construct of which confidentiality is one type, referred to as informational privacy. Confidentiality and privacy are related to providers’ attitudes and behaviours. In a recent literature review of the health and health care needs of lesbian, gay, and bisexual (LGB) adolescents, Coker et al. (2010) surmised that LGB youth wanted health care professionals to provide private and confidential services. Among 12-17 year old students in Australia, Booth et al. (2004) reported that the most important barrier for utilizing health services for a range of health concerns, including sexuality issues, was that confidentiality would not be kept, both in terms of service providers keeping disclosures confidential and being seen attending a service.

Berhane et al. (2005) found that 41% of adolescents in their Ethiopian study believed providers were confidential, 21% of adolescents did not believe providers were confidential, while 36%

reported not knowing whether providers were confidential. These are important findings because any uncertainty regarding providers’ ability to maintain confidentiality could prevent utilization for sensitive matters such as sexuality issues. However, the large proportion of adolescents with positive views of provider confidentiality is very promising.

Nonetheless, some health facilities and providers are deemed more confidential than others.

Adolescents in Uganda were reportedly of the view that health centres lacked confidentiality, and as a result preferred to use traditional healers and drug shops. Furthermore, Langhaug et al. (2003) noted that confidentiality could be breached if a private space for consultation with

adolescents is lacking. Also, male adolescents in Langhaug et al.’ (2003) study reported that confidentiality is breached because “sometimes you are taken into a private room. But the moment you say out your problem the nurses may invite other nurses to ‘come and see what I have here’ (p.152). In contrast, some adolescents use both Western and traditional providers because they considered both to be confidential (Biddlecom et al., 2007; Kumi-Kyereme et al., 2007). However, most adolescents in Biddlecom et al. (2007) study did not go to health facilities, despite positive expectations regarding government facilities.