Thesis (MPH) -- University of Limpopo, 2012. / Background: Youth friendly services were introduced in all the ten districts t of Lesotho to meet the adolescents health needs including reproductive health of adolescents. Despite this initiative there is still a high prevalence of teenage pregnancy and human immunodeficiency virus (HIV) infection among young people. Aim: The aim of the study was to investigate the utilization, and factors influencing the utilization of reproductive health services (RHS) among high school adolescents in Thaba-Tseka district of Lesotho. Methodology: This was a quantitative descriptive cross-sectional study. The study population was adolescents aged between 13 -19 years in the two high schools in the district. A total of 800 adolescents were asked to complete a structured, self-administered questionnaire. Descriptive statistics were used to summarise demographics, sexual activity, experience of sexually transmitted infections (STIs), and awareness and use of RHS. The chi-square test was used to identify associations between categorical variables, and binary logistical regression modelling was used to identify significant predictors of utilisation of RHS. Results: The response rate was 97.5% (780/800), but only 723 questionnaires had sufficient data to be analysed. The mean age of respondents was 16.4 years with a standard deviation of 1.7years. Of the respondents, 49.5% (358/723) had been sexually active with the youngest age at sexual debut of 8 years. Of these, 71.5% (256/358) were presently sexually active; 82.4% (295/358) had low overall levels of awareness of RHS; 37.9% (136/358) had ever visited the adolescent health corner (AHC); 34.9% (125/358) reported that there was a place that provided RHS in their local clinic; 57.3% (205/358) had ever used condoms; and 56.7% (203/358) had experienced a STI; Of those presently sexually active, 89.5% (229/256) used some form of contraceptive, with 95.2% (218/229) buying condoms from a retail shop although only 94.0% (205/218) reported using them, while 38.9% (89/229) also obtained them from the AHC. Only 13.3% (27/203) of those who had experienced signs of STI ever visited the AHC for treatment. Of those who knew about RHS, 54.4% (68/125) utilized the services. Statistically significant predictors of RHS utilization were having a friend using RHS (odds ratio [OR] =8.87; P value< 0.001) and access to RHS (OR=7.97; P < 0.001). Participants in higher grades were significantly less likely to use RHS compared to participants in lower grades (OR=0.21; P<0.001). Conclusion: Almost half of the adolescents engage in sexual activity at an early age and RHS are under-utilised, mostly because of lack of access. There is a need to embark on increasing accessibility of RHS among adolescents to promote utilization of RHS.

Sex and sexuality issues are still sensitive and controversial subjects despite the growing numbers of sexual and reproductive health (SRH) programmes for adolescents in subSaharan African countries (WHO, 2002; Department ofInternational Development (DFID), 2004). The purpose of this study was to examine and analyze the structure and procedural mechanisms adopted by adolescent sexual and reproductive health (SRH) programmes in two African countries. This study also explored the adolescents' perceived usefulness and relevance of these programmes in addressing their SRH needs. The study was conducted in Ghana (West Africa) and South Africa (Southern Africa) as a cross-national study in these two sub-Saharan African countries. A comparative case study design was adopted involving the use of both quantitative and qualitative approaches to data collection and analysis. Snowballing, critical case, and purposive sampling methods were used. A wide range of personnel from both countries including programme directors, managers, nurse/midwives, peer educators and youth counselors (n=48) were interviewed within the context of adolescent sexual and reproductive health (ASRH) programmes and adolescents (n=247) participated through client exit surveys and focus group discussions. Records review, document analysis and observation of the facilities were employed through a checklist. A Tri-dimensional conceptual framework adapted from Donabedian (1980) and WHO (2001) for: (1) Structure, (2) Process, and (3) Output of ASRH programmes, guided the study and served as the frame for analysis and comparison. Qualitative data were transcribed and analyzed using framework analysis and quantitative data through use of SPSS Version 13.0. Findings of the study revealed that both Ghana and South Africa have established ASRH structures through development of programmes and policies for young people. They also shared common features related to programme focus and philosophy on ASRH matters. Both countries face several challenges associated with sexuality issues, inadequate human and material resources. Religious, socio-cultural, logistical and structural factors were identified as barriers, which hindered access and use of the facilities. These barriers were found to have a profound influence on programme implementation, achievement of objectives and future development. Adolescents in the two countries are confronted with a range of issues affecting their sexual health and general well-being for which they seek services from ASRH programmes. These programmes in both countries were generally perceived as relevant and important by youth utilizing the facilities. The need for changes in the attitude of service providers, structural layout, logistical improvement and staffing composition was expressed. Despite efforts made, there are still programmatic issues needing attention, for which specific recommendations towards improvement were made on the basis of findings from both countries. Findings from this study have implications for nursing practice, management, education, research and relevant stakeholders involved with adolescent health, including policy makers. Recommendations are made that may contribute to the development of an effective model of "Adolescent-Friendly" programmes in the two countries. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2007.

Report-in-lieu-of-Thesis (M.P.H.)--University of North Texas Health Science Center at Fort Worth, 2008. / Title from title page display. Bibliography: p. 58-61.

Introduction: Federally qualified health centers (FQHCs) and health departments (HDs) are essential in providing contraceptive care and ensuring reproductive autonomy for adolescents. Through offering adolescent-specific services and by training providers in adolescent-specific care and patient-centered contraceptive counseling, clinics can ensure access to high quality contraceptive care for adolescents. Despite the significant decrease in adolescent pregnancy rates, rates remain high in the South and in rural counties, suggesting that clinics in these areas may not have the capacity to provide adolescent-specific services and patient-centered counseling. This study compares the capacity to provide adolescent-specific and patient-centered contraceptive services in rural and urban FQHCs and HDs in two southeastern states -- South Carolina (SC) and Alabama (AL). Methods: Data were collected from a statewide survey of FQHC and HD clinics in SC and AL in 2020. A total of 239 clinics were included (FQHC N=112 and HD N=127) and were identified as rural (N=101) or urban (N=138) using Rural-Urban Continuum Codes. Capacity to provide patient-centered adolescent care is defined as 1) a clinic offering adolescent-specific services; 2) providers at the clinic receiving training in patient-centered counseling; and 3) providers receiving training in adolescent-specific care. To measure capacity, these three survey items were dichotomized into Yes/No responses and then combined into a new variable to measure clinics who responded Yes to each survey item. The type of adolescent-specific services was also measured as being onsite, offsite, outreach, or none. Capacity to provide patient-centered adolescent care was compared across clinics located in rural and urban settings and by clinic type. Statistical differences were determined using the Chi-Square test of independence (α= 0.05). Results: Overall, 44.8% of participating clinics in SC and AL had the capacity to provide patient-centered adolescent contraceptive services. Approximately 51.8% of rural and 66.1% of urban HDs reported the capacity to provide adolescent-specific services. In contrast, 26.7% of rural and 35.4% of urban FQHCs reported the capacity to provide adolescent-specific services. Approximately 55.4% of rural and 71.4% of urban HDs provided any adolescent-specific services, but fewer rural HDs (30.2%) provided onsite services than urban HDs (59.3%) (p=0.003). Fewer than half of rural (42.2%) and urban (48.8%) FQHCs provided adolescent-specific services, with approximately 23.8% of rural and 27.9% of urban sites providing onsite services. Conclusions: The capacity of clinics in SC and AL to provide contraceptive counseling to adolescents, which is anchored in reproductive autonomy, is contingent upon the provision of adolescent-specific services and provider training. Most clinics, especially rural clinics, did not have the capacity to provide patient-centered contraceptive counseling to adolescents. This gap in services may contribute to the higher adolescent pregnancy rates in rural areas of SC and AL. Clinics in SC and AL, especially FQHCs, should develop policies that support adolescent-specific contraceptive services and provider training.

INTRODUCTION) Modern contraception is a safe and effective clinical service for reducing unintended pregnancy and improving birth spacing for women. Provider counseling is an important factor that may influence women’s decision making, satisfaction, and self-efficacy with contraception use. This study measures women’s perceptions of recent provider interactions and examines the extent to which these perceptions are associated with method satisfaction and confidence in use. We hypothesize that women who perceive more positive interactions are ultimately more satisfied and confident with their contraceptive method choice. METHODS) A cross-sectional survey of adult reproductive-aged women in two southern states (aged 18 to 44 years old) was used for the analysis. The Statewide Survey of Women was conducted in 2017 by NORC at the University of Chicago. Women were asked to rate providers across a series of statements reflecting aspects of patient-centered contraceptive counseling using a 5-point Likert scale. Responses were dichotomized to reflect those with very good/excellent experiences compared to those with less favorable experiences (Poor, Fair, Good). Women were subsequently asked about their level of satisfaction with current contraceptive methods and confidence in use, also using a 5-point Likert scale. These measures were also dichotomized. A chi-squared test for independence and unadjusted logistic regression models were used to examine associations between patient-provider interactions, satisfaction and confidence in contraceptive use. FINDINGS) The survey included 4,281 respondents. The majority of women reported being satisfied with their current contraceptive method (92.6%) and confident in its use (94.9%). Approximately 93% of women who felt respected as a person by their provider also reported being satisfied with their current birth control method, compared to 73% among women who did not feel respected as a person (p<0.001). Among women who felt their provider allowed them to say what mattered to them about their birth control method, 93.5% were satisfied with their current method, compared to 75% among those who did not feel allowed to say what mattered (p<0.001). Women who felt like their provider took their preferences for birth control into consideration were also more satisfied with their current birth control method compared to those who did not feel the same way (93.7% versus 73.5%; p<0.001). Women who felt their provider allowed them to say what mattered and those who felt their provider took their preferences into consideration were also associated with higher rates of confidence in correct use. Women reporting that their provider gave them enough information to make the best decision about their birth control method was also associated with greater confidence in correct use (95.6% versus 87.5%; p=0.007). CONCLUSION) Findings suggest that positive patient-provider interactions are associated with increased satisfaction in current contraceptive method use. Interestingly, women reporting that providers did not give them enough information to make the best decision about birth control methods also reported being less confident in using their current method. Collectively, these findings support existing evidence suggesting that patient-provider interactions are important for patient-centered care and can be used to inform future clinical practice guidelines around contraceptive counseling.

Introduction: Improving the quality of contraceptive care that youth receive improves the patient-provider relationship, satisfaction with care, and contraceptive method use and continuation. In recent years, high-quality contraceptive care for youth has shifted away from tiered effectiveness counseling and toward youth-friendly, person-centered contraceptive counseling (YFPCCC). Rooted in the reproductive justice movement, YFPCCC requires that counseling encourages youth to say what matters to them in their contraceptive method, respects youth’s preferences in their contraceptive method, provides youth with the information necessary to make the best choice for them, and is respectful of youth’s choices. YFPCCC is especially important for minor youth and youth of color who have historically received biased care and for youth in the United States South where restrictive policies may prevent youth from receiving care. This study examined youths’ perspectives of YFPCCC at safety-net clinics in two states in the U.S. South. Methods: Between 2018 and 2022, a survey measuring patient perspectives of their contraceptive counseling was collected from youth (ages 16 to 24) who received care at federally qualified health centers (FQHCs) and health departments (HDs) in Alabama (AL) and South Carolina (SC). A total of 1,052 youth were included in the study (AL n=513 and SC n=539). Four survey items measuring the four components of person-centered counseling and two survey items measuring youth-friendliness (knowledgeable and trustworthy providers) were dichotomized into Yes/No responses and combined to create two new variables measuring PCCC and providers’ youth-friendliness. PCCC and youth friendliness were compared across clinic type, state, age, race/ethnicity, and insurance coverage using logistic regression. P-values less than 0.05 were considered significant. Results: Overall, 56% of youth in the study reported that they received all four components of PCCC and 71% reported that their providers were youth-friendly. Minor youth (ages 16 and 17) were 34% less likely than older youth (ages 20-24) to report receipt of PCCC (aOR 0.66, 95% confidence interval (CI) [0.45, 0.98]). Minor youth were also 39% less likely than older youth to report that their provider was youth-friendly (aOR 0.61, 95% CI [0.40, 0.93]). Non-Hispanic Black youth were 45% less likely than non-Hispanic White youth to report PCCC (aOR 0.55 95% CI [0.40, 0.70]). Similarly, non-Hispanic Black youth were 44% less likely than non-Hispanic White youth to report that their provider was youth-friendly (aOR 0.56 CI [0.41, 0.77]). Discussion: Providing contraceptive care that is both person-centered and youth-friendly is essential in improving the quality of care that youth receive. In this study, minors and non-Hispanic Black youth were the least likely to report that their care was both person-centered and youth-friendly. This gap in the quality of care that non-Hispanic Black youth receive may contribute to lower satisfaction with care which may contribute to lower contraceptive use rates and higher unintended teen birth rates for this group. Clinics can improve their ability to provide YFPCCC by ensuring providers are trained in youth-friendly and person-centered contraceptive care.

The need to expand access to and availability of quality and comprehensive sexual and reproductive health care (SRH) to help close the gaps in existing health disparities and health inequities in the United States is a pressing public health concern. The emergence of alternative primary care settings (i.e., retail-based clinics [RBCs]) has recently proven to be an effective model for the delivery of acute care in lieu of more traditional medical services. Indeed, RBCs could be an agent for greater SRH care access with the integration of more services; however, barriers exist that inhibit this maximization of care. Providers play a central role in the utilization of SRH in RBCs, whether through their intent to recommend or biases about RBCs. Provider recommendation is a strong indicator for patient compliance. However, little is known about how providers’ attitudes and beliefs influence the uptake of SRH in RBCs. This cross-sectional study collected survey data from a large sample of 341 advanced practice clinicians (APC) to (1) understand the benefits and barriers of SRH integration in RBCs; and (2) identify the relationship between the attitudes of APCs regarding RBCs and their influence on barriers and benefits of SRH integration into RBCs. Items were adapted from existing valid and reliable measures. Survey data were analyzed primarily using descriptive statistics. Comparative analysis between demographic factors and identifier variables that led to several themes: a majority of APCs believe the integration of SRH into RBCs would expand access to and availability of quality and comprehensive SRH care for prevention and intervention; hesitancy to recommend SRH services is chiefly founded in lack of confidence in quality assurance, professional training and quality of services offered; overall APCs had a generally positive attitude towards the integration of SRH in RBCs but attitudes differed among the types of SRH services offered at RBCs. These findings provide insight for the identification of barriers and benefits in the integration of SRH in RBCs. This may create opportunities to address barriers for the expansion of prevention and intervention services among women while capitalizing on benefits to advance awareness, education and access to care.

More than 50 million people were forcibly displaced from their homes at the end of 2014, the highest number since World War II; 38 million of these were displaced within their own country rather than crossing an international border. Many have been displaced multiple times by chronic and recurring conflict. Complex humanitarian emergencies caused by armed conflict are characterized by social disruption, population displacement and the breakdown of national health systems. The negative impact of war and displacement on women has long been recognized, including by compromising their right to sexual and reproductive health (SRH) services. The ten countries with the highest maternal mortality ratios in the world are affected by, or emerging from, war; these countries are also characterized by low contraceptive prevalence. The provision of SRH services is a minimum standard of health care in humanitarian settings; however access to these services is still often compromised in war. A 2012-2014 global evaluation on the status of SRH in humanitarian settings showed that although access to SRH services has improved in humanitarian settings, gaps persist and the availability of contraceptive services and information is still weak relative to other SRH components. This dissertation addresses this gap by providing evidence that good quality contraceptive services can be implemented in humanitarian settings and that women and couples will choose to start and continue contraceptive use. The first paper of this dissertation, a systematic review, explored the evidence regarding SRH services provided in humanitarian settings and determined if programs were being evaluated. In addition, the review explored which SRH services received more attention based on program evaluations and descriptive data. Peer-reviewed papers published between 2004 and 2013 were identified via the Ovid MEDLINE database, followed by a PubMed search. Papers on quantitative evaluations of SRH programs, including experimental and non-experimental designs that reported outcome data, implemented in conflict and natural disaster settings, were included. Of 5,669 papers identified in the initial search, 36 papers describing 30 programs met inclusion criteria. Some SRH technical areas were better represented than others: seven papers reported on maternal and newborn health (including two that also covered contraceptive services), six on contraceptive services, three on sexual violence, 20 on HIV and other sexually transmitted infections and two on general SRH topics. In comparison to the program evaluation papers identified, three times as many papers were found that reported SRH descriptive or prevalence data in humanitarian settings. While data demonstrating the magnitude of the problem are crucial and were previously lacking, the need for SRH services and for evaluations to measure their effectiveness is clear. Contraceptive services were mostly limited to short-acting methods and received less attention overall than other SRH technical components. In response to this lack of evidence for the implementation of contraceptive services in humanitarian settings, two contraceptive services programs implemented by CARE and Save the Children among conflict-affected populations in eastern Democratic Republic of the Congo (DRC) were evaluated. DRC has experienced chronic conflict for two decades, ranging from acute to post conflict phases. People have been displaced internally for many years while others have experienced repeated cycles of displacement and return. First, cross-sectional surveys in 2008 (n=607) and 2010 (n=575) of women of reproductive age using a multi-stage cluster sampling design and facility assessments were conducted in Maniema province. Data on the numbers of clients who started a contraceptive method were also collected monthly from supported facilities. Current use of any modern contraceptive method doubled from 3.1% to 5.9% (adjusted OR 2.03 [95%CI 1.3-3.2]). Current use of long-acting and permanent methods (LAPM) increased from 0 to 1.7%, an increase that was no longer significant after adjustment. Program changes were made to improve service quality in 2010; provider skills and counseling improved and commodities became consistently available. Service statistics indicate that the percentage of clients who accepted a LAPM at supported facilities increased from 8% in 2008 to 83% in 2014. This study demonstrates that when good quality contraceptive services, including LAPM, are provided among conflict-affected populations, women will choose to use them. Second, a retrospective cohort study measured 12-month contraceptive continuation in North Kivu province. A total of 548 women (304 short-acting and 244 long-acting method acceptors) were interviewed about their contraceptive use in the previous year. At 12 months, 81.6% women reported using their baseline method continuously, with more long-acting than short-acting method acceptors (86.1% versus 78.0%, p=.02) continuing method use. Use of a short-acting method (HR 1.74 [95%CI 1.13-2.67]) and desiring a child within two years (HR 2.32 [95%CI 1.33-4.02]) were associated with discontinuation at 12 months. Given the association between service quality and contraceptive continuation, the program’s focus on service quality including improvements to provider skills and activities to address provider attitudes likely contributed to these results. The impressive continuation rates found here indicate that delivering high quality contraceptives services in these settings is possible, even in a difficult and unstable setting like eastern DRC. This dissertation represents a major contribution to the field of SRH in humanitarian settings, and has implications for research and programs. First, these results strengthen the evidence base for the implementation of contraceptive services in humanitarian settings, and demonstrate to implementers and donors of humanitarian aid that effective programs resulting in adoption and continuation of contraceptive methods can be successfully implemented in these challenging settings. Second, these programs were implemented in full collaboration with the Ministry of Health (MOH), supporting MOH facilities and health workers, thus strengthening the health system. Third, the programs achieved these impressive results in rural DRC where they attracted early adopters, most of them first time contraceptive acceptors. In addition, these programs were implemented by multi-sectoral, as opposed to SRH-specific, non-governmental organizations that made good quality contraceptive services a priority, further reinforcing the inclusion of contraceptive services as a routine component of humanitarian health response. Finally, both programs evaluated in this dissertation focused strongly on improving the quality of contraceptive services with specific attention to training, supervision, provider attitudes, data use and commodities management. This program focus on quality contributed to the positive findings. Making good quality contraceptive services available is challenging and requires sustained commitment, funding and program adjustments, but, in the programs studied here, was ultimately successful. Given true choice, when a range of methods was routinely available, women, many of whom had no prior experience with contraceptive use, were able to choose the method that best served their needs and continued to use their preferred method. These results add to the limited evidence on contraception in humanitarian settings, and demonstrate that even in remote and unstable settings, when good quality contraceptive services, with a choice of short-acting, long-acting and permanent methods, are in place, women will not only choose to start, but also continue, to use contraception to exercise their right to reproductive choice.

The study aimed to explore adolescents knowledge, perceptions and behaviors regarding sexual reproduction and sexual reproductive health services in community junior school in Tutume Botswana. A descriptive exploratory design using both the qualitative and quantitative approach was used to guide the research process. Data was collected by means of a self administered questionnaire and two focus group discussions. A total of 76 participants answered the questionnaire and 2 focus group discussions one consisting of the 15 to 17 year olds and the other one consisting of 12 to 15 year olds were conducted. The results of the survey highlighted adequate levels of knowledge regarding sexual matters among adolescents in the school with the bulk of the information being provided by the teacher. Parents, nurses, siblings, peers and the media played a low key role in providing adolescents with information regarding sexual reproduction and sexual reproductive health services. The results of the focus group discussion showed marked underutilization of the local clinic for curative, preventive and promotive services by adolescents. The poor utilization resulting mainly from perceived barriers such as provider attitudes, subjective norms, cultural taboos, inadequacy of the clinic, judgmental attitudes from provider and parents as well as lack of encouragement from authority figures like parents and teachers. Adolescents in the focus group discussion perceive themselves as being susceptible to HIV but did not appreciate the benefits of using preventive measures even though the survey group showed sound knowledge on contraception. Improving the services to align them to adolescent friendly services, improving the delivery of information through other means apart from the teacher and reducing the barriers that discourage adolescents from reaching the reproductive health services will go a long way in improving the utilization of the services by adolescents. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2009.

Thesis (M.P.H.M. (Primary Health Care Management))--Mahidol University, 2006. / LICL has E-Thesis 0011 ; please contact computer services.