Youth clinics may be answer to improved healthcare for youngsters
Special youth clinics appear to be an effective means of providing healthcare services to young people who otherwise might not engage with healthcare services. But is building more youth clinics realistic given our resource constraints, or is it better to focus on making ‘normal’ clinics more youth-friendly — or should we be looking beyond clinic-based healthcare services altogether?
Getting young people to access healthcare services in the public sector is often an uphill battle. One solution is to have special clinics catering just for the youth.
Pumeza Runeyi, a health officer at Doctors without Borders (MSF), was involved in setting up two such clinics in Khayelitsha in Cape Town. She says there is a myriad of reasons why young people don’t want to go to general clinics — she highlights the fact that some young people fear bumping into neighbours or relatives at the clinic. “At times, it is just the fear of being judged. They will see you taking condoms or [other] contraceptives then you are judged for being sexually active,” she says.
“Our idea was to have a safe place for the youth, where it will be just them served by their peers who most of the time understand their challenges and can relate to what they are going through and walk this journey with them,” she says.
Getting the youth to access especially sexual and reproductive health services is crucial. According to Thembisa, the leading model of HIV in South Africa, there were around 63,000 new HIV infections in people aged 15 to 24 in 2021 and around 3 000 Aids deaths. In addition, the rate of unplanned pregnancies in South Africa remains high, with over 35,000 teen pregnancies in the first quarter of 2021, underlining the need for easy access to a variety of contraceptive options. When young women do fall pregnant, it is important that they engage with the healthcare system throughout their pregnancy and afterwards.
“Nurses aren’t trained or sensitised to adolescent needs and preferences, stigma, prejudicial views. Hours may not suit adolescents and the waiting and queues aren’t welcome and often the services aren’t tailored to adolescents’ needs,” says Professor Linda-Gail Bekker, director of the Desmond Tutu HIV Centre. She explains that adolescent-friendly services often include a near-peer, a peer navigator, or a welcome face to help facilitate the passage through the clinics.
“Adolescents also prefer a ‘one-stop shop’ rather than the fragmented referral-based systems we often present in our current services. Recognising that most adolescents do not have chronic illnesses or non-communicable diseases, we probably can supply most of their needs through sexual and reproductive health services, including HIV care as well as mental health support,” says Bekker.
Runeyi, who co-authored an article in the Journal of the International AidsS Society that looked at the performance of the two clinics in Khayelitsha, adds that the two clinics in Khayelitsha had rooms for games and music. She says the health talks are always age-appropriate.
In 2018, the two MSF’s clinics were handed over to the City of Cape Town which now runs it.
The Site B Youth Clinic was established in 2014 and provides services including Basic Antenatal Care, sexual reproductive health services, TB and ART services, health education, PrEP, and ART support groups. The Site C Youth Clinic was established in 2004 and provides the same basket of services as well as termination of pregnancy services.
No plans to open more youth clinics
At the two clinics from July 2019 to June 2020, a total of 36,528 youth were served, in July 2020 to June 2021, 33 682 youth served and from July 2021 to May 2022, a total of 31,302 youth were served.
Though these clinics have drawn a number of youths through their doors, Mayoral Committee Member for Community Services and Health, Councillor Patricia Van der Ross says there are no immediate plans to open more youth clinics. She says, instead, City Health has made strides in introducing specific times and spaces at existing facilities for younger clients so all their clinics are now youth-friendly.
In March this year, during the Fogarty International Centre’s (FIC) annual meeting, Bekker called for adolescent-friendly approaches to create sustainable HIV care for adolescents. In a news update on the FIC website, Bekker is quoted as having said that “Adolescent-friendly” means tailored services with flexibility around timing and accessibility provided alongside relevant, confidential information. “And where possible there are comprehensive services integrated into the mix and when referrals are needed, they come with navigation assistance, preferably peer navigation.”
According to van der Ross, they have introduced a number of measures in recent years to create youth-friendly services. Some of these measures include training clinic staff to be sensitive towards young people seeking sexual health and reproductive services, using queue marshals to fast-track learners needing family planning services, introducing youth clinics or set hours focusing on youth services, introducing a new appointment system, encouraging follow-up visits as well as developing engaging educational material and making it available in clinic waiting areas.
Runeyi says the City is doing its best given the circumstances. “We have always asked for stand-alone youth clinics but the challenge has always been infrastructure. However, the City is really trying to adapt and make clinics youth-friendly. This is by having hours that cater for the youth, allowing the youth to be served at certain times where it is just them in the facility, and it works well,” she says.
According to Bekker, some studies are being done on the uptake of sexual and reproductive health services in different models and more data will hopefully be forthcoming. Some findings already published based on work done in Malawi among adolescent girls, showed that adolescent-friendly services had better uptake compared to care offered in “adult-oriented spaces”, but rigorous evaluation is needed.
The MSF youth clinics were designed for people aged 12 to 25. This, begs the question — how will services be delivered for a 12-year-old, a 25-year-old, or a 34-year-old and still remain youth-friendly.
“That’s the million-dollar question,” says Bekker.
“Are we willing to invest in youth to say they may need tailored services above what adults need in order to ensure they receive the health care and prevention services they need? This needs to be viewed as a triple dividend — invest in adolescent health [and] this leads to healthier adolescents, healthier adults tomorrow, and healthier parents in the future,” she tells Spotlight.
Taking services to the youth
Spotlight previously published an article reporting on how PrEP was delivered at schools through mobile busses providing a healthcare service at schools. PrEP (pre-exposure prophylaxis) is antiretrovirals that are taken by HIV-negative people to prevent HIV infection.
Prodding Bekker on which is better — creating youth-friendly services in clinics or taking the service to the users, she says it is great to consider all models, including mobile services.
“Should we try to make the services more adolescent-friendly (integrate) or create clinics that are adolescent-specific (parallel clinics), or actually set up parallel services outside of public sector clinics? I think we may need all of the above to really understand which is most popular in an area and which model meets the most needs,” she says.
While the City has outreach services in schools and other community settings, van der Ross says having dedicated timeslots for young people at clinics is easier, particularly since resources are not infinite.
Based on the numbers, there is good uptake of sexual and reproductive health and other services among youth in the City of Cape Town’s clinics.
“The statistics in the latest media release show that young people are definitely making use of many of the services that are available to them,” says van der Ross.
In the 2020/21 financial year (1 July 2020 to 30 June 2021), City clinic clients in the 15 to 34 age group accounted for 85.15% of clients accessing PrEP, 84.1% of clients on Basic Antenatal Care, 78.5% of clients receiving services relating to sexually transmitted infections (STIs), 64.9% of clients who had HIV tests, and 39% of clients accessing TB services, to mention a few.
According to Bekker, having terrific and tailored adolescent-friendly services alone is not enough, and the demand side must also be addressed. “There is a need for demand creation. You don’t just build cafés and sit back expecting sales in Coca-Cola to go up. Coca-Cola goes out and actively and creatively markets [its] product which drives people into the cafes to get their cokes,” she says.
Van der Ross says the City, through ongoing education and awareness as well as outreach activities to schools and going into communities, and by using a range of communication tools, draws young people to the clinics.
Van der Ross stresses that it is important to destigmatise reproductive health needs, particularly for young people under the age of 18. “While abstinence will always be the ideal, the reality is that young people are sexually active and the health system, therefore, needs to adapt to ensure that it is able to provide these crucial, life-saving services to young people without judgment,” she says.
Runeyi says what they have found is that those who attended youth clinics usually stay on treatment. “This just goes to show the importance of [a] good foundation. Though they would really like to stay at youth clinics, they can’t because of [their] age. Services are different at general clinics, however, they adhere to their clubs and treatment even in those circumstances,” she says. DM/MC
*This article was published by Spotlight – health journalism in the public interest.
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