Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A GUIDE TO IMPLEMENT A STANDARDS-DRIVEN APPROACH TO IMPROVE THE QUALITY OF HEALTH-CARE SERVICES FOR ADOLESCENTS

Volume 1: Standards and criteria

©MARCO DORMINO/UN PHOTO

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A guide to implement a standards-driven approach to improve the quality of health-care services for adolescents

Volume 1: Standards and criteria

WHO Library Cataloguing-in-Publication Data Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents. Volume 1: Standards and criteria 4 v. Contents: Volume 1: Standards and criteria - Volume 2: Implementation guide - Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards Volume 4: Scoring sheets for data analysis 1.Adolescent Health Services – standards. 2.Quality of Health Care. 3.Adolescent. 4.Data Collection. 5. Health Care Surveys – methods. 6.National Health Programs. I.World Health Organization. ISBN 978 92 4 154933 2 (NLM classification: WA 330)

© World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/ about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland Cover photos (clockwise from top left): Marcelo Campi, Vancouver Public Library, Ahmad Khan, Edith Kachingwe, Camila Rugenia Design by Inís Communication – www.iniscommunication.com

CONTENTS Acknowledgments Abbreviations Glossary Introduction Background How this document was developed Global standards for quality health-care services for adolescents Standards’ rationale, intent and criteria Implementation Implementation plan Implementation process Key reference documents This document is part of the Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health-care services for adolescents. It is one of four volumes published separately, which include: • Volume 1: Standards and criteria • Volume 2: Implementation guide • Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards • Volume 4: Scoring sheets for data analysis

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ACKNOWLEDGMENTS The World Health Organization (WHO) is grateful to UNAIDS and all those who gave technical input into the production of this document. Lead writers: Subidita Chatterjee (independent consultant) and Valentina Baltag (WHO). WHO working group: Paul Bloem, Krishna Bose (formerly WHO), Venkatraman Chandra-Mouli, Charlotte Christiansen (formerly WHO), Jane Ferguson, Nuhu Yaqub.  Peer review (WHO): Anastasyia Dumcheva, (WHO Country Office in Ukraine), Symplice Mbola Mbassi (WHO Regional Office for Africa), Howard Sobel (WHO Regional Office for the Western Pacific). Peer review (UNAIDS): staff members. Peer review (external review group): Regina Benevides (Evidence to Action, United States of America), Doortje Braeken (International Planned Parenthood Federation, United Kingdom), Scott Burnett (loveLife, South Africa), Danielle Engel (United National Population Fund, United States of America), Mychelle Farmer (Jhpiego, United States of America), Bamikale Feyisetan (Evidence to Action, United States of America), Gwyn Hainsworth (Pathfinder International, United States of America), Jari Kempers (Qalys Health Economics, Estonia), Vijay Kumar (Survival for Women and Children Foundation, India), Catherine Lane (United States Agency for International Development, United States of Amercia), Laura Laski (United National Population Fund, United States of America), Galina Lesco (National Resource Centre in YFHS “Neovita”, Republic of Moldova), Ricky Lu (Jhpiego, United States of America), Elizabeth Mapella (Ministry of Health, United Republic of Tanzania), Edgar Necochea (Jhpiego, United States of America), Beth Outterson (Save the Children, United States of America), Elizabeth Saewyc (University of British Columbia, Canada), Olena Sakovych (United Nations Children’s Fund, Ukraine), Susan Sawyer (University of Melbourne, Australia), Kat Watson (International Planned Parenthood Federation, United Kingdom), Sylvia Wong (United National Population Fund, United States of America). Editing: Jura Editorial Services, Gex, France.

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ABBREVIATIONS HMIS health management information systems NGO nongovernmental organizations SOP standard operating procedure WHO World Health Organization

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GLOSSARY Adolescent – WHO defines adolescents as people between 10 and 19 years old. Assent – Refers to children’s and adolescents’ participation in decision-making on health care and research intervention(s) by giving an agreement. Assent is not regulated by law as is consent, and it is sometimes referred to as a moral obligation closely linked to good practice in dealing with patients. It emphasizes that in all cases, whether or not the consent of the parent/guardian is required, the voluntary, adequately informed, non-forced and non-rushed assent of the adolescent should be obtained (see also informed choice, informed consent). Attitude – A person’s views about a thing, process or person, which influence behaviour. Community health worker – Any health worker who performs functions related to health-care delivery in the community. Community health workers have received training on the interventions and activities they are involved in, but have not received formal professional, paraprofessional or tertiary education. They are normally members of the communities where they work, selected by the communities, answerable to the communities for their activities and should be supported by the health system. Competency – Sufficient knowledge and psychomotor, communication and decision-making skills and the attitudes to enable the performance of actions and specific tasks to a defined level of proficiency. Confidentiality – The right of an individual to privacy of personal information, including health-care records. This means that access to personal data and information is restricted to individuals who have a reason and permission for such access. The requirement to maintain confidentiality governs not only how data and information are collected (e.g. a private space in which to conduct a consultation), but also how the data are stored (e.g. without names and other identifiers) and how, if at all, the data are shared. Criterion (of a standard, see also standard) – A measurable element of a standard that defines a characteristic of the service that needs to be in place (input criterion) or implemented (process criterion) in order to achieve the defined standard (output criterion). Evolving capacity – The capacity of an adolescent to understand matters affecting his or her life and health change with age and maturity. The more an adolescent “knows, has experienced and understands, the more the parent, legal guardian or other persons legally responsible for him or her can transform direction and guidance into reminders and advice, and later into exchange on an equal footing.”1 In health care it means that as the adolescent matures, his or her views have increasing weight in choices regarding care. The fact that the adolescent is very young or in a vulnerable situation (e.g. has a disability, belongs to a minority group, is a migrant) does not deprive him or her of the right to express his or her views, nor does it reduce the weight given to the adolescent’s views in determining his or her best interests,2 and, hence, choices regarding aspects of care. 1

The General comment No. 12 of the Convention of the Rights of the Child, page 17. http://www2.ohchr.org/english/bodies/ crc/docs/AdvanceVersions/CRC-C-GC-12.pdf. The General comment No. 14 of the Convention of the Rights of the Child, page 13, paragraph 13. http://www2.ohchr.org/ English/bodies/crc/docs/GC/CRC_C_GC_14_ENG.pdf. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS vii

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Gatekeeper(s) – Adults that have influence over adolescents’ access to and use of services, e.g. parents and/or other family members, legal guardians, teachers, community leaders. Health literacy – The cognitive and social skills that determine the motivation and ability of an adolescent to gain access to, understand and use information in ways that promote and maintain good health. Informed choice – A choice made by an adolescent regarding elements of his or her care (e.g. treatment options, follow-up options, refusal of service for care) as result of adequate, appropriate and clear information in order to understand the nature, risks, alternatives of a medical procedure or treatment and their implications for health and other aspects of the adolescent’s life. If there is more than one possible course of action for a health condition, or if the outcome of a treatment is uncertain, the advantages of all possible options must be weighed against all possible risks and side-effects. Also, the views of the adolescent must be given due weight based on his or her age and maturity1 (see also evolving capacity). Informed consent – A documented (usually written) agreement or permission accompanied by full and clear information on the nature, risks and alternatives of a medical procedure or treatment and their implications before the physician or other health-care professional begins the procedure or treatment. After receiving this information, the adolescent (or the third party authorized to give the informed consent) either consents to or refuses the procedure or treatment. The procedures and treatments requiring informed consent are stipulated in country laws and regulations. Many procedures and treatments do not require informed consent; however, they all require that the adolescent is supported to make an informed choice and give an assent if so desired (see also assent, informed choice and evolving capacity). Key populations – Refers to defined groups who, due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviours that increase their vulnerability to HIV (Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization; 2014, http://www.who.int/hiv/pub/guidelines/keypopulations/en/). Their engagement is critical to a successful HIV response; they are key to the epidemic and key to the response. Key populations include men who have sex with men, people in prisons and other closed settings, people who inject drugs, sex workers and transgender people. Adolescent members of key populations are more vulnerable than adults in the same groups, and people may be part of more than one key population. Other priority populations at high risk include the seronegative partners in serodiscordant relationships and the clients of sex workers. Also, there is a strong link between various kinds of mobility and heightened risk of HIV exposure, depending on the reason for mobility and the extent to which people are outside their social context and norms. Each country should define the specific populations at higher risk that are critical to their epidemic and response based on the epidemiological and social context (http://www.unaids.org/ sites/default/files/media_asset/JC2118_terminology-guidelines_en_0.pdf p18). Outreach (health-care delivery) – Any health-related activity coordinated by the health system that takes place off-site (outside the health facility premises). Outreach activities can be performed by healthcare providers (for example, primary care nurses that perform classroom health education or doctors that perform medical check-ups in schools), or by outreach workers (see definition below). The purpose of outreach activities in adolescent health care is to reach adolescents by bringing services close to where they are: schools, universities, clubs, churches, workplaces, street settings, shelters or wherever young 1

The General comment No. 14 of the Convention of the Rights of the Child, page 13, paragraph 53. http://www2.ohchr.org/ English/bodies/crc/docs/GC/CRC_C_GC_14_ENG.pdf.

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people gather. Examples of outreach activities include health education and distribution of commodities such as condoms. Outreach worker – Any volunteer who performs functions related to outreach health-care delivery on behalf of the health system. Outreach workers are not health-care professionals, but receive special training to perform their functions. An example of an outreach worker is a peer educator (see definition below). Peer education – The process whereby specially trained adolescents undertake informal or organized educational activities with their peers (those similar to themselves in age, background or interests). These activities, occurring over an extended period of time, are aimed at developing adolescents’ knowledge, attitudes, beliefs and skills and at enabling them to be responsible for and to protect their own health. Examples of activities that peer educators carry out include co-teaching or guest lecturing during a health education session in school; leading a group discussion in the waiting room of a health facility; doing educational outreach and referrals with “street adolescents” in an urban area; providing information on contraception and distributing condoms to adolescent members of key populations at higher risk of HIV exposure1 (see also key populations); presenting a theatre piece or role play at a community health fair or other event. Peer educator – An adolescent who was specially trained to perform peer education. Reward (extrinsic, intrinsic) – Extrinsic rewards – financial or other – are the tangible rewards given to employees by managers, such as pay for performance, bonuses, and benefits. They are called extrinsic because they are external to the work itself, and other people control their size and whether or not they are granted. In contrast, intrinsic rewards are psychological rewards that employees get from doing meaningful work and performing it well. Some examples of intrinsic rewards in health care are the sense of expertise and competence (e.g. the feeling of being an expert on adolescent health care and providing high-quality services) and the sense of professional progress (e.g. seeing convincing signs that changes in the process of care accomplish something, such as adolescents in the community being more satisfied with the care provided and having better health and development outcomes). Rights – Adolescents’ health-related rights include at least the following: • Care that is considerate, respectful and non-judgemental of the adolescent’s unique values and beliefs. Some values and beliefs are commonly held by all adolescents or community members and are frequently cultural and religious in origin. Others are held by the adolescent client alone. Strongly held values and beliefs can shape the care process and how adolescents respond to care. Thus, each health-care provider must seek to provide care and services that respect the differing values and beliefs of adolescents. Also, health-care providers should be non-judgemental regarding adolescents’ personal characteristics, life style choices or life circumstances. • Care that is respectful of the adolescent’s need for privacy during consultations, examinations and treatments. Adolescent privacy is important, especially during clinical examinations and procedures. Adolescents may desire privacy from other staff, other patients, and even family members. Staff members must learn their adolescent clients’ privacy needs and respect those needs. • Protection from physical and verbal assault. This responsibility is particularly relevant to very young adolescents and vulnerable adolescents, the mentally ill, and others unable to protect themselves or signal for help.

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• Information that is confidential and protected from loss or misuse. The facility respects information as confidential and has implemented policies and procedures that protect information from loss or misuse. Staff respect adolescent confidentiality by not disclosing the information to a third party unless legally required, by not posting confidential information or holding client-related discussions in public places. • Non-discrimination, which is the right of every adolescent to the highest attainable standard of health and quality health care, without discrimination of any kind, irrespective of the adolescent’s or his or her parent’s or legal guardian’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. • Adolescent participation in care processes. Unless the decision-making capacity is delegated by law to a third party, or the adolescent lacks decision-making capacity as assessed by the relevant authority,1 the adolescent decides about all aspects of care, including refusing care. The adolescent also decides which family member and friends, if any, participate with him or her in the care process. Adolescents’ involvement in care is respected irrespective of whether or not the adolescent has a legal capacity for decision-making. An adult’s judgement of an adolescent’s best interests cannot override the obligation to respect all rights of adolescents as stipulated in the Convention of the Rights of the Child.2 This includes the right of the adolescent who is capable of forming his or her own views to express those views freely in all matters affecting him or her, and having those views given due weight in accordance with the age and maturity3 (see also evolving capacities). The facility supports and promotes adolescent involvement in all aspects of care by developing and implementing related policies and procedures. Standard – A statement of a defined level of quality in the delivery of services that is required to meet the needs of intended beneficiaries. A standard defines the performance expectations, structures or processes needed for an organization to provide safe, equitable, acceptable, accessible, effective and appropriate services. Support staff – Individuals who provide indirect patient care (for example, receptionists, secretaries) or who are involved in maintaining certain quality standards (e. g. cleaning or security staff).

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In many countries health-care providers have the authority to assess whether or not the adolescent has decision-making capacity; in some circumstances the decision may be taken in court. The General comment No. 13 of the Convention of the Rights of the Child. http://www2.ohchr.org/english/bodies/crc/docs/ CRC.C.GC.13_en.pdf Article 12 of the Convention of the Rights of the Child. http://www.ohchr.org/en/professionalinterest/pages/crc.aspx

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INTRODUCTION The World Health Organization report Health for the world’s adolescents: a second chance in the second decade suggests that to make progress toward universal health coverage, ministries of health and the health sector more generally will need to transform how health systems respond to the health needs of adolescents. It recommends developing and implementing national quality standards and monitoring systems as one of the actions necessary to make this transformation. Global initiatives are urging countries to prioritize quality as a way of reinforcing human rightsbased approaches to health. Yet, evidence from both high- and low-income countries shows that services for adolescents are highly fragmented, poorly coordinated and uneven in quality. Adolescents often find mainstream primary care services unacceptable because of perceived lack of respect, privacy and confidentiality, fear of stigma and discrimination and imposition of the moral values of health-care providers. Pockets of excellent practice exist, but, overall, services need significant improvement. Recognizing these problems, many countries have moved towards a standards-driven approach to improve the quality of care for adolescents. With ministry of health leadership, more than 25 countries have adopted national quality standards, and some, including Malawi, the Republic of Moldova, South Africa, Tajikistan, Ukraine and the United Republic of Tanzania, have conducted surveys to measure the quality of the services being provided in order to inform action (WHO, 2014a). Building on country experience and on previous World Health Organization (WHO) guidance documents – Quality assessment guidebook: a guide to assessing health services for adolescent clients (2009) and Making health services adolescent friendly (2010) – this publication presents global standards for quality health-care services for adolescents, an implementation guide and monitoring tools. It aims to support health-care planners and facility managers in the organization and delivery of health-care services in a way that responds to adolescents’ needs. The intent of the standards is to guide service delivery and quality improvements in all primary and referral facilities not just in a few showcase centres. By making improvements in the quality of care provided, adolescents’ rights to accessible, acceptable and effective care will be fulfilled. This document aims to inform and assist national public health programme managers, facility managers, health-care providers, national bodies in charge of quality improvement, as well as individuals and organizations supporting their work, such as development agencies, nongovernmental organizations (NGOs) and the commercial sector.

The aim of Global standards for quality health-care services for adolescents is to assist policy-makers and health service planners in improving the quality of health-care services so that adolescents find it easier to obtain the health services that they need to promote, protect and improve their health and well-being. The implementation plan and the monitoring tools that accompany the standards in this document provide guidance on identifying what actions need to be taken to implement the standards and to assess whether the standards have been achieved. The primary intention of the standards is to improve the quality of care for adolescents in government healthcare services; however, they are equally applicable to facilities run by NGOs and those in the private sector. The ultimate purpose of implementing the standards is to increase adolescents’ use of services and, thus, to contribute to better health outcomes.

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BACKGROUND How this document was developed Development of these standards was a five-stage collaborative process involving many departments in WHO and other stakeholders. The various steps are outlined below and depicted in Fig.1.

Analysis of national standards from 25 countries WHO developed the global standards based on the needs assessment, which was informed by the literature review and online surveys, in conjunction with the analysis of 26 national standards from 25 countries: Bangladesh, Bhutan, Burkina Faso, Congo, Ethiopia, Ghana, India, Indonesia, Kyrgyzstan, Lesotho, Malawi, Mongolia, Myanmar, Nicaragua, Philippines, Republic of Moldova, South Africa, Sri Lanka, Tajikistan, Thailand, Ukraine, United Kingdom (England, Scotland), United Republic of Tanzania, Viet Nam, and Zambia. The analysis of national standards identified the most common standards11 and their criteria,2 which were then reviewed against the findings of the literature review and global surveys. Actions from

Needs assessment through a literature review and two global surveys WHO commissioned an analysis of published and unpublished systematic reviews and metaanalyses from January 2000 to June 2013 on existing facilitators and barriers to improving the quality of health care for adolescents related to provision of information, communication with providers, engagement with health-care services, regulations and standards, organizational capacity and satisfaction of adolescent clients (Nair M et al., 2015). In addition, two online global surveys were conducted by WHO in 2013, one with primary care providers and the other with adolescents. These surveys informed the global report Health for the world’s adolescents: a second chance in the second decade. Both surveys were conducted online via SurveyMonkey. The survey with primary care providers included questions on accessibility, quality improvement, providers’ skills, facility policies regarding equity, confidentiality, privacy and informed consent, financial protection and users’ fees, and other aspects relevant to quality of care for adolescents. The survey was answered by 735 respondents from 81 countries representing all six WHO regions. The survey with adolescents was open to all adolescents between 12 and 19 years old. There were responses from 1143 adolescents from 104 countries. The key areas addressed in the survey were: i) adolescents’ understanding of health, including the factors that influence it; ii) adolescents’ views about priorities among health issues; iii) barriers to and use of health services; and iv) adolescents’ opinions about how their health could be improved.

Fig. 1. The process for development of the global standards for quality healthcare services for adolescents Needs assessment • Literature review of published and unpublished literature • Global survey with primary care providers • Global survey with adolescents

Analysis of national standards from 25 countries

Review by the technical working group

Peer review

Field test and consolidation

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the countries’ implementation plans informed the implementation guide for the global standards. The monitoring tools were informed by the data collection tools from WHO’s Quality assessment guidebook: a guide to assessing health services for adolescent clients (2009); questions were adapted and added as needed to measure the standards and criteria.

Review by the technical working group WHO formed a technical working group that included representatives from the Department of Maternal, Newborn, Child and Adolescent Health, the Department of Reproductive Health and Research, and the Department of Immunization, Vaccines and Biologicals. This group reviewed the draft resulting from the combined analysis of national standards and their implementation plans and findings of the needs assessment.

reviewers representing national and international experts from governments and academia,4 NGOs and development partners5 reviewed the document. At this stage no radical changes were recommended to the standards’ areas. However, there were useful suggestions for better emphasis of the human rights-based approach, avoiding redundancies between criteria and ensuring that the criteria measured all important aspects of standards. There were also proposals for the structure of the document, which added considerably to its clarity.

Field test and consolidation The pre-final draft was subsequently field-tested in Benin for the national adaptation and in a regional expert consultation of Latin American and Caribbean countries that took place in November 2014. The consultation aimed to develop regional sexual and reproductive health standards using the global standards. The field test showed that the document was adequate for both national and regional contexts, and no substantial changes were suggested.

Peer review After the technical working group review, WHO regional and country offices3 and external

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A standard was considered common if it was found in at least 50% of reviewed countries’ standards. A criterion was considered common if it was found in at least 25% of reviewed countries’ criteria. WHO Country Office in Ukraine, WHO Regional Office for Africa, WHO Regional Office for Europe, WHO Regional Office for the Western Pacific. Australia, Estonia, India, Republic of Moldova, United Republic of Tanzania. Evidence to Action, International Planned Parenthood Federation, Jhpiego, loveLife, Pathfinder International, Save the Children, United Nations Children’s Fund, United Nations Population Fund. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 3

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GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS Eight global standards define the required level of quality in the delivery of services as shown in the table below. Each standard reflects an important facet of quality services, and in order to meet the needs of adolescents all standards need to be met. This section presents each of these standards and its criteria, categorized as input, process and output criteria.

Adolescents’ health literacy

Standard 1. The health facility implements systems to ensure that adolescents are knowledgeable about their own health, and they know where and when to obtain health services. Standard 2. The health facility implements systems to ensure that parents, guardians and other community members and community organizations recognize the value of providing health services to adolescents and support such provision and the utilization of services by adolescents. Standard 3. The health facility provides a package of information, counselling, diagnostic, treatment and care services that fulfils the needs of all adolescents. Services are provided in the facility and through referral linkages and outreach.1 Standard 4. Health-care providers demonstrate the technical competence required to provide effective health services to adolescents. Both healthcare providers and support staff respect, protect and fulfil adolescents’ rights to information, privacy, confidentiality, non-discrimination, non-judgemental attitude and respect. Standard 5. The health facility has convenient operating hours, a welcoming and clean environment and maintains privacy and confidentiality. It has the equipment, medicines, supplies and technology needed to ensure effective service provision to adolescents. Standard 6. The health facility provides quality services to all adolescents irrespective of their ability to pay, age, sex, marital status, education level, ethnic origin, sexual orientation or other characteristics. Standard 7. The health facility collects, analyses and uses data on service utilization and quality of care, disaggregated by age and sex, to support quality improvement. Health facility staff is supported to participate in continuous quality improvement. Standard 8. Adolescents are involved in the planning, monitoring and evaluation of health services and in decisions regarding their own care, as well as in certain appropriate aspects of service provision.

Community support

Appropriate package of services Providers’ competencies

Facility characteristics

Equity and nondiscrimination

Data and quality improvement

Adolescents’ participation

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Service provision in the facility should be linked, as relevant, with service provision in referral level health facilities, schools and other community settings.

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Standards’ rationale, intent and criteria Standard 1 – Adolescents’ health literacy The health facility implements systems to ensure that adolescents are knowledgeable about their own health, and they know where and when to obtain health services.

Rationale for Standard 1 Evidence suggests that adolescents do not have adequate health literacy (see Glossary) to enable them to gain access to, understand and effectively use information in ways that promote and maintain their good health (WHO, 2014a). Health literacy

is critical to empowerment and includes, among other things, the timely recognition of the need for health or other services; the ability to seek advice and care, including successfully making appointments; and the ability to navigate through the sometimes complicated system of services available. Yet, adolescents often are not aware of what health or other services are being provided (e.g. educational and vocational support, drug and alcohol counselling, legal and social support), where they are provided and how to obtain them (WHO, 2011a; WHO, 2014a). In addition, health literacy means more than just being able to read pamphlets and successfully make appointments. Adolescents often lack accurate knowledge regarding health and disease,

Measurable criteria of Standard 1 Input criteria 1. The health facility has a signboard that mentions operating hours.1 2. The health facility has in the waiting area up-to-date information, education and communication materials specifically developed for adolescents. 3. Health-care providers have competencies2 to provide health education to adolescents and to communicate about health3 and available services (health, social and other services4). 4. The health facility has outreach workers5 that are trained to conduct health education for adolescents in the community. 5. The health facility has a plan for outreach activities and/or involvement of outreach workers in activities to promote health and increase adolescents’ use of services. 1 2

Process criteria 6. Health-care providers provide age and developmentally appropriate health education and counselling to adolescent clients and inform them about the availability of health, social services and other services. 7. Outreach activities to promote health and increase adolescents’ use of services are carried out according to the health facility’s plan.

Output criteria 8. Adolescents are knowledgeable about health. 9. Adolescents are aware of what health services are being provided, where and when they are provided and how to obtain them.

If there are special days and/or hours for adolescents, these should be clearly mentioned. Competencies (see Glossary) are defined in a job description; see Core competencies in adolescent health and development for primary care providers at http://www.who.int/maternal_child_adolescent/documents/core_competencies/en/. This includes not only knowledge about an adolescent’s own health status, but also knowledge about positive health behaviours, risk and protective factors and health determinants. Other services that adolescents might need may include shelters, recreational services, vocational training services or services provided by agencies that finance care, provide transportation. This includes community health workers, health volunteers, peer educators. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 5

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health-related behaviours, risk and protective factors, and the social determinants of health (WHO 2014a). This knowledge is crucial to increase adolescents’ motivation and encourage actions which may lead to a modification of healthrelated behaviours and risk or resilience factors. Many sectors, primarily the education sector, have responsibilities to contribute to adolescents’ health literacy. Within this collective effort, healthcare facilities and health-care providers play an important role. Adolescents value the active listening skills of clinicians and the clarity and amount of information provided to them (Ambresin A-E et al., 2012). Adolescents’ positive experience of care depends also on the availability of teenoriented leaflets and up-to-date health information in the waiting room, including television or games (Ambresin A-E et al., 2012). Standard 1, therefore, stresses the importance of health education (within the facility and through outreach) and individual behaviour-oriented communication that will develop adolescents’ skills and knowledge, and their efficacy to act on their knowledge, in order to maintain good health.

of services, health-care providers and working hours of the facility. In addition, adolescents are informed about other services available in the community, such as social services, shelters, recreational services, vocational training services or services provided by agencies that finance care or provide transportation. The facility, thus, maps other care providers, governmental and NGOs and community agencies that can serve adolescents, and develops a network of services and referrals with them (see also Standard 3).

Standard 2 – Community support The health facility implements systems to ensure that parents, guardians and other community members and community organizations recognize the value of providing health services to adolescents and support such provision and the utilization of services by adolescents.

Rationale for Standard 2 Parents, guardians, family and community and religious leaders play an important role in supporting adolescents to access and use services. Evidence suggests that without gatekeepers’ (see Glossary) support, adolescent health programmes are not successful (WHO, 2014a; Denno DM et al., 2015). In many countries unmarried adolescents have little support to access and use sexual and reproductive health services (Chandra-Mouli et al., 2014). This standard, thus, sets expectations for the level of support for adolescents’ use of services from parents, guardians and other community members.

Intent of Standard 1 Health education is carried out in both the health facility and the community (see also Standard 2). Informational materials use a language, format and comprehension level appropriate to adolescents of various ethnic and age groups. To help adolescents better understand the available health services, information is clearly communicated about types

Intent of Standard 2 The health facility informs community members about the value of providing health services to adolescents either during visits to the facility or through outreach (see Glossary). However, merely informing community members about the importance of adolescents’ use of health-care services is not enough. To ensure that parents, guardians and other community members support all adolescents – married and unmarried, younger and older – to use the health services they need, it is essential that the facility engage in partnerships with community members and organizations to develop health education and communication strategies and materials, to get their buy-in and to plan service provision. Involving adolescents in this work is also essential (see also Standards 1 and 8). ©HAURANITAI SHULIKA

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Measurable criteria for Standard 2 Input 10. Health-care providers have competencies1 and support materials to communicate with parents, guardians and other community members and organizations about the value of providing health services to adolescents. 11. The health facility has an updated list of agencies and organizations with which it partners to increase community support for adolescents’ use of services. 12. The health facility has a plan for outreach activities and/ or involvement of outreach workers in activities to increase gatekeepers’ support for adolescents’ use of services. Process 13. The health facility engages in partnerships with adolescents, gatekeepers and community organizations to develop health education and behaviour-oriented communication strategies and materials and plan service provision. 14. Health-care providers inform parents/guardians visiting the health facility about the value of providing health services to adolescents. 15. Health-care providers and/or outreach workers inform parents/ guardians and teachers during school meetings about the value of providing health services to adolescents. 16. Health-care providers and/or outreach workers inform youth and other community organizations about the value of providing health services to adolescents. Output 17. Gatekeepers and community organizations support the provision of health services to, and their utilization by, adolescents.

Standard 3 – Appropriate package of services The health facility provides a package of information, counselling, diagnostic, treatment and care services that fulfils the needs of all adolescents. Services are provided in the facility and through referral linkages and outreach.2

Rationale for Standard 3 Comprehensive care – care that responds to the full range of health problems of an individual or in a given community – is widely recognized as key to the overall quality of care (WHO, 2015b). Evidence suggests that important causes of mortality and morbidity, and their risk factors, do not get sufficient attention in primary care nor in many initiatives labelled “adolescent-friendly”, which often focus on a limited range of issues,

such as sexual and reproductive health (WHO, 2014a). For example, mental health problems, which are the main cause of illness and disability among adolescents, are often neglected (WHO, 2014a). Other problems that do not get sufficient attention relative to the burden of disease they cause include nutrition, substance use, intentional and unintentional injuries and chronic illness. Sexual and reproductive health, including HIV in adolescents, remains a critical health concern in many regions; however, it is important that other contributors to the burden of disease are adequately addressed. Comprehensive means not only that care responds to the full range of health problems, but also that care for any condition encompasses, in a coherent way, health promotion and prevention, as well as diagnosis and treatment or referral (WHO, 2015b).

1

Competencies (see Glossary) are defined in a job description; see Core competencies in adolescent health and development for primary care providers at http://www.who.int/maternal_child_adolescent/documents/core_competencies/en/. Service provision in the facility should be linked, as relevant, with service provision in referral level health facilities, schools and other community settings. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 7

2

Evidence shows that health services are often clinically oriented and opportunities for preventive interventions are frequently overlooked. Further, health-care providers often do not have clear guidance as to which services are important to provide to their adolescent clients.

Intent of Standard 3 Standard 3 stresses three important elements. First, health care for adolescents encompasses a range of services such as information, counselling, diagnosis, treatment and care. Second, the package of services offered in the facility reflects the health-care needs of adolescents in the community(ies). While priorities might vary from country to country, and from community to community, adolescents need services in a range of areas – mental health, sexual and reproductive health, HIV, nutrition and physical activity, injuries and violence, substance use, and immunization (see also Standards 7 and 8). WHO-recommended services and interventions for adolescents can be

found in the WHO report Health for the world’s adolescents: a second chance in the second decade.1 Third, it is very important that the facility determines exactly what services are to be offered on-site and what services are to be made available through referral and outreach (see Glossary). Successful care requires a close interrelationship between the network of services within and outside the health sector. Within the health sector, strong links between the health facility and the community(ies) served by the facility should exist, as well as between various levels of the healthcare system and between various specialties. For instance, planning the transition from childcentred to adult-centred health care was found to be an important indicator of the quality of adolescent health care (Ambresin A-E et al., 2012), and requires good coordination and joint planning for the transition between paediatrician and general practitioner. In countries where school health services exist, close collaboration between the health-care facility and school health personnel

Measurable criteria for Standard 3 Input 18. Policies are in place that define the required package2 of health information, counselling, diagnostic, treatment and care services and enable its provision. 19. Policies and procedures3 are in place that identify which health services are provided in the health facility and which in community settings such as schools.4 20. Policies and procedures are in place that describe the referral system to services within and outside the health sector, including provisions for transition care for adolescents with chronic conditions. 1 2

Process 21. Health-care providers provide the required package of health information, counselling, diagnostic, treatment and care services in the facility and/or in community settings, in line with policies and procedures.5 22. Service providers refer adolescents to the appropriate service and level of care according to local policies and procedures, and follow the policies for transition care.

Output 23. The health facility provides a package of health services that fulfils the needs of all adolescents, in the facility and/ or through referral linkages and outreach.

Available at http://apps.who.int/adolescent/second-decade/section6/page1/universal-health-coverage.html. While countries may prioritize services according to the local situation, the range of services that adolescents require usually includes mental health, sexual and reproductive health, HIV, nutrition and physical activity, injuries and violence, substance use, and immunization. To inform countries’ efforts in articulating national packages of adolescent health services, see WHO recommended services and interventions for adolescents at http://apps.who.int/adolescent/second-decade/section6/ page1/universal-health-coverage.html. Standard operating procedures are desired where possible; these should be periodically updated. Services in the community may be provided by a wide range of both volunteer and paid health providers that work within and among the community, and are often referred to as community health workers. Evidence-based management in line with guidelines and protocols is covered in Standard 4.

3 4

5

8 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

should exist to ensure coordination, continuity of care and joint actions in the community. In addition, coordination with and referral to social, educational, recreational, transportation, legal and other services outside the health sector should be implemented. Within its area, the facility identifies the health- and non-health-related agencies that may serve as public or private referral sources for adolescents and related agencies that finance care, provide transportation or provide specialized services. The facility, thus, develops a network of other care providers, governmental and NGOs and community agencies to meet the health needs of adolescents in the community(ies) (see also Standard 2). In addition, some services may be offered through outreach, either by health-care providers themselves (e.g. prevention education and/or regular check-ups in schools), or by collaborating with trained outreach workers (see Glossary).

use of certain services or to withhold certain services from adolescents – for example, refusing to provide contraception to unmarried sexually active adolescents (Chandra-Mouli et al., 2014). Insufficient respect in clinical practice for adolescents’ rights to information, privacy, confidentiality, non-discrimination and nonjudgemental attitudes is a major barrier to adolescents’ use of services (WHO, 2014a). Therefore, hand in hand with developing technical competencies in adolescent health care, there is a need to assess and, where needed, change providers’ attitudes towards adolescents and their right to quality health care (WHO, 2015a).

Intent of Standard 4 Standard 4 sets the expectations for the technical and attitudinal competencies required of providers for effective care, including competencies related to a human rights-based approach to adolescent health care. Importantly, the latter also applies to support staff (see Glossary). These competencies are detailed in the Core competencies in adolescent health and development for primary care providers (WHO, 2015a). They emphasize that health-care providers should be competent not only in managing adolescents in specific clinical situations, but also in demonstrating awareness of one’s own attitudes, values and

Standard 4 – Providers’ competencies Health-care providers demonstrate the technical competence1 required to provide effective health services to adolescents. Both healthcare providers and support staff respect, protect and fulfil adolescents’ rights to information, privacy, confidentiality, non-discrimination, nonjudgemental attitude and respect.

Rationale for Standard 4 Health-care providers’ attitudes, knowledge and skills are at the core of quality service provision (Ambresin A-E et al., 2012; WHO, 2010; WHO, 2015a). Guideline-driven care is central to young people’s positive experience of care (Ambresin A-E et al., 2012). Yet, many healthcare professionals report insufficient knowledge of and technical competence in adolescent-specific aspects of health promotion, disease prevention and management. Many providers do not feel confident to communicate effectively about such issues as domestic and school violence, family or intimate partner relationships, and nutrition or substance use (WHO, 2014a). In addition, health-care providers’ own attitudes and beliefs may lead them to discourage the 1

©JACOB JUNGWOO HAN

See Core competencies in adolescent health and development for primary care providers at http://www.who.int/maternal_ child_adolescent/documents/core_competencies/en/. A WHO guideline recommends, for example, the provision of sexual and reproductive health services, including contraceptive information and services, for adolescents without mandatory parental and guardian authorization/notification, in order to meet the educational and service needs of adolescents (WHO, 2014b). GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 9

prejudices that may interfere with the ability to provide confidential, non-discriminatory, nonjudgemental and respectful care to adolescents. To ensure technical competence, the facility ensures that the number, qualifications and skill mix of staff is adequate to deliver the required package of adolescent care services (see also Standard 3), and to meet the facility’s mission and objectives vis-a-vis adolescent health care. To maintain acceptable staff performance, ensure

up-to-date management of conditions, teach new skills or new aspects of equipment and procedures, the facility provides opportunities for in-service training and other education. Even when formal continuous professional education systems in adolescent health care do not exist, the facility uses flexible learning opportunities such as seminars, supportive supervision, case reviews, access to online information resources and distance learning to maintain staff performance.

Measurable criteria of Standard 4 Input 24. Health-care providers and support staff of the required profile1 are in place. 25. Health-care providers have the technical competencies2 necessary to provide the required package of services. 26. Health-care providers have been trained/sensitized on the importance of respecting the rights of adolescents to information, privacy, confidentiality, and of the health care that is provided in a respectful, non-judgemental and nondiscriminatory manner. 27. Providers’ obligations and adolescents’ rights3 are clearly displayed in the health facility. 28. Up-to-date decision support tools (guidelines, protocols, algorithms) that cover topics of clinical care in line with the package of services are in place. 29. A system of supportive supervision is in place to improve health-care providers’ performance. 30. A system of continuous professional education that includes an adolescent health-care component is in place to ensure lifelong learning. 1 2

Process 31. Health-care providers follow evidencebased guidelines and protocols in delivering care to adolescents. 32. Health-care providers and support staff relate to adolescents in a friendly manner, and respect their rights to information, privacy, confidentiality, non-discrimination, non-judgemental attitude, and respectful care.

Output 33. Adolescents receive effective4 health services. 34. Adolescents receive services in a friendly, supportive, respectful, non-discriminatory and non-judgemental manner, and know their rights in health care. 35. Adolescents receive accurate, ageappropriate and clear information to facilitate informed choice.

The required competencies of staff should be clear in job descriptions. Competencies should encompass all areas of the package (e.g. mental health, sexual and reproductive health, violence prevention), as well as the entire range of services as delineated in Standard 3 (information, counselling, diagnosis, treatment and care). This includes rights (see Glossary) to information, privacy, confidentiality, non-discrimination, non-judgemental attitude, and respectful care. Effectiveness is measured against evidence-based standards of care (e.g. criterion-based audit) using a combination of methods, such as an audit of medical records and observation. Tools to measure the effectiveness of care of selected conditions are currently being developed and are not part of this guide.

3

4

10 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Up-to-date decision support tools, such as clinical practice guidelines and protocols, are used to ensure effective care and minimize variations in care. Clinical practice guidelines and protocols may be adapted from external sources or created by staff within the facility. Regardless of the source, the scientific basis of a guideline should be evaluated and all clinical practice guidelines and protocols should be reviewed and approved by the facility’s leaders and clinical practitioners before implementation. This will ensure that the guidelines and protocols are standardized to accommodate local and regional practice and the health-care and disease realities of adolescents in the community(ies). The facility advances health-related rights (see Glossary) for all its adolescent clients to ensure they have the services they need. The manager(s) provides direction to ensure that staff assume responsibility for protecting these rights. Obtaining health care may be frightening and confusing for adolescents, making it difficult for them to understand and act on their rights. Thus, the facility clearly displays a written statement of adolescents’ rights, and adolescents are made aware of this statement when they seek services from the facility (see also Standards 6 and 8). The statement is appropriate for adolescents’ age, understanding, and language. When written communication is not effective or appropriate, the adolescent is informed of his/her rights in a manner he/she can understand. Health-care providers and support staff respect, protect and fulfil adolescent rights throughout the care process.

addition, adolescents may not use the facility if they perceive it to be equipped inadequately, or lack the necessary drugs and supplies.

Intent of Standard 5 Standard 5 stresses, therefore, the importance of the organizational and design features of the facility that are important to provide accessible, efficient, and safe clinical care in a secure and supportive environment. The standard has three elements: one deals with the organization of operating hours and an appointment system to meet the needs of adolescents; the second stresses the importance of design features and local policies to maintain privacy and confidentiality; and the third emphasizes the importance of systems to ensure adequate equipment, drugs and supplies. To make the care process seamless for the adolescent, the facility takes actions to support an adolescent-focused process such as: • the operating hours are convenient for adolescents in the community(ies) • care may be provided on an appointment basis or a walk-in basis • the adolescent appointment and registration processes are respectful of the adolescent’s time and are designed to minimize waiting times. The facility plans and implements actions to manage the physical environment to ensure that it is clean, safe and accessible to all adolescents. Maintaining privacy and confidentiality is a matter of staff attitudes (see Standard 4), but it is also a matter of how the facility is designed. Design features that enable privacy, confidentiality and safety include the following: • Offices/examining rooms are designed to ensure privacy for patients during clinical examinations and treatments. • Adequate hand hygiene facilities are located in or adjacent to the office/exam room. • Adequate seating is provided in the waiting room for normal patient flow, in a manner that ensures privacy of communication with reception staff. • The premises, fittings, and furniture are kept clean and in good repair, meeting standards for lighting, heating, ventilation, and infection control. • The facility provides for safe storage and disposal of clinical waste and potentially infectious waste that require special disposal, such as sharps/needles and other disposable equipment that may have come in contact with body fluids.

Standard 5 – Facility characteristics The health facility has convenient operating hours, a welcoming and clean environment and maintains privacy and confidentiality. It has the equipment, medicines, supplies and technology needed to ensure effective service provision to adolescents.

Rationale for Standard 5 Evidence suggests that the process of care can be confusing and even overwhelming for an adolescent. Convenient operating hours (e.g. outside of school hours) and flexible appointment procedures (e.g. the possibility of a consultation without an appointment) are important for adolescents’ access to services (Ambresin A-E et al., 2012; WHO, 2010). The facility’s physical environment (cleanliness, design features that enable privacy and confidentiality) is a characteristic highly valued by adolescents (Ambresin A-E et al., 2012). In

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 11

• Security is provided to assure the safety of the environment, the premises and offices/exam rooms. In addition to design features, policies and procedures are in place that maintain adolescents’ confidentiality at all times (except where staff are obliged by legal requirements to report incidents such as sexual assaults, road traffic accidents or gunshot wounds, to the relevant authorities). Policies and procedures address: • registration – information on the identity of the adolescent and the presenting issue are gathered in confidence; • consultation – confidentiality is maintained throughout the visit of the adolescent to the point of health service delivery (i.e. before, during and after a consultation);

• record-keeping – case-records are kept in a secure place, accessible only to authorized personnel; the facility also considers unauthorized access to electronically stored information and implements processes to prevent such access; • disclosure of information – staff do not disclose any information given to or received from an adolescent to third parties such as family members, school teachers or employers, without the adolescent’s consent. The facility implements actions for inspecting, testing, and maintaining medical equipment and documenting the results. The facility has a system for procurement and stock management of the medicines and supplies necessary to deliver the required package of services to adolescents.

Measurable criteria of Standard 5 Input 36. A policy is in place, including assigned responsibilities across health-care providers and support staff, to ensure a welcoming and clean environment,1 minimize waiting times and ensure convenient operating hours and flexible appointment procedures. 37. The facility has basic amenities (electricity, water, sanitation and waste disposal). 38. Policies and procedures to protect the privacy and confidentiality of adolescents are in place. Both health-care providers and support staff know them as well as their own roles and responsibilities. 39. A system of procurement and stock management of the medicines and supplies necessary to deliver the required package of services is in place. 40. A system of procurement, inventory, maintenance and safe use of the equipment necessary to deliver the required package of services is in place. 1

Process 41. Health-care providers offer consultations during hours that are convenient to adolescents in local communities, with or without an appointment. 42. Health-care providers and support staff follow policies and procedures to protect the privacy and confidentiality of adolescents. 43. Medicines and supplies are in adequate quantities without shortages (stock-outs), and are equitably used. 44. The equipment necessary to provide the required package of services to adolescents is available, functioning and equitably used.

Output 45. The health facility has convenient operating hours, appointment procedures and waiting times kept to a minimum. 46. The health facility has a welcoming and clean environment. 47. Adolescents receive private and confidential health care at all times during the consultation process. 48. The facility has the equipment, medicines, supplies and technology needed to ensure effective service provision to adolescents.

This includes a comfortable seating area, available drinking water, educational materials in local language(s) that are attractive to adolescents, clean surroundings, waiting area and toilets.

12 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Standard 6 – Equity and nondiscrimination The health facility provides quality services to all adolescents irrespective of their ability to pay, age, sex, marital status, education, ethnic origin, sexual orientation or other characteristics.

(Chandra-Mouli et al., 2014). In addition, out-ofpocket payments that have a deterrent effect on access to services for any population group may have a disproportionate effect on adolescents because of their limited access to cash and dependence on family resources (Waddington C and Sambo C, 2015).

Rationale for Standard 6 Evidence suggests that some groups of adolescents within the community may fall outside the planning and service delivery system because they are less visible, are socially marginalized or stigmatized or do not have advocates (WHO, 2014a; Waddington C and Sambo C, 2015). For example, unmarried adolescents may be stigmatized if they seek STI and HIV testing, safe abortion (where it is legal) or contraceptive services

Intent of Standard 6 This standard stresses the importance of providing equitable care so that all adolescents, not just certain groups, are able to obtain the health services they need. It stresses that equity concerns all dimensions of quality of care outlined in these standards. That is, equity is observed not just in the levels of service use by various groups of adolescents, but also in, for example, the level of respect, application of technical competence,

Measurable criteria of Standard 6 Input 49. Policies and procedures are in place stating the obligation of facility staff to provide services to all adolescents irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other characteristics. 50. Policies and procedures are in place for services that are free at the point of use, or affordable. 51. Health-care providers and support staff are aware of the above policies and procedures, and know how to implement them. 52. The policy commitment of the health facility to provide health services to all adolescents without discrimination, and to take remedial actions when necessary, is displayed prominently in the health facility. 53. Health-care providers know who are the vulnerable group(s) of adolescents in their community(ies). 1

Process 54. Health-care providers and support staff demonstrate the same friendly, nonjudgemental and respectful attitude to all adolescents, regardless of age, sex, marital status, sexual orientation, cultural background, ethnic origin, disability or any other reason. 55. Health-care providers provide services to all adolescents without discrimination, in line with policies and procedures. 56. The health facility involves vulnerable group(s) of adolescents in the planning, monitoring and evaluation of health services, as well as in certain aspects of healthservice provision.

Output 57. All adolescents – irrespective of their ability to pay, age, sex, marital status, education, ethnic origin, sexual orientation or other characteristics – report similar experiences of care.1,2 58. Vulnerable group(s) of adolescents are involved in the planning, monitoring and evaluation of health services, as well as in certain aspects of healthservice provision.3

This includes the experience of care alongside all dimensions of quality of care as outlined in these standards (e.g. access to information, staff attitude, communication, guideline-driven care). This criterion can be measured by comparing the experience of care in groups of adolescents with various socio-economic characteristics. For example, as peer educators, counsellors, trainers.

2

3

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 13

use of medicines and technologies, involvement in the care process and its planning and monitoring that various groups of adolescents experience. The facility works collaboratively with other agencies and health-care providers to identify vulnerable group(s) of adolescents in their community(ies), understand the needs of these groups, and involve them in the planning, monitoring and evaluation of health services (see also Standards 2 and 8). The facility provides equitable care and treatment for adolescents with the same health problems and care needs. Providers use guidelines and protocols that ensure a high level of patient care (see Standard 4), which is applied to all groups of adolescents in an equitable manner. Clinical and managerial leaders plan and coordinate policies and procedures to ensure equity, monitor that this equity is observed at all times and to take remedial actions when necessary. The facility has policies and procedures for services that are free at the point of use, or affordable, to adolescents.

Standard 7 – Data and quality improvement The health facility collects, analyses and uses data on service utilization and quality of care, disaggregated by age and sex, to support quality improvement. Health facility staff is supported to participate in continuous quality improvement.

Rationale for Standard 7 Effective policy-making for adolescent health care and programme design requires strategic information on the health-related behaviours of adolescents and about available health services for them. For the latter, data that come from routine facility data collection and facility assessments of services and service quality are extremely important (WHO, 2014a). Through facility-level registers health management information systems (HMIS) collect data that includes client information about age, sex, presenting problem, diagnosis and services provided. However, in most low and middle income countries, by the time these

Measurable criteria for Standard 7 Input 59. A system is in place to collect data on service utilization that is disaggregated by age, sex and other socio-demographic characteristics as relevant. 60. Health-care providers are trained to collect and analyse data to inform quality improvement initiatives. 61. Tools and mechanisms for selfmonitoring of the quality of health services for adolescents are in place. 62. Mechanisms are in place to link supportive supervision to priorities for improvement as identified during the monitoring of the implementation of standards. 63. Mechanisms are in place for reward and recognition of highly performing health-care providers and support staff. 1

Process 64. The health facility collects data on service utilization disaggregated by age and sex, and conducts regular self-assessments of quality of care.1 65. Health-care providers and support staff use data on service utilization and quality of care for action planning and implementation of quality improvement initiatives. 66. Health-care providers and support staff receive supportive supervision in areas identified during self-assessments. 67. Good performance is recognized and rewarded.

Output 68. Facility’s reports to districts include data on cause-specific utilization of services by adolescents that is disaggregated by age and sex. 69. Facility’s reports to districts on quality of care have a focus on adolescents. 70. Health facility staff feel supported by supervisors and motivated to comply with the standards.

This includes the assessment of adolescents’ experience of care. See Standard 8.

14 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

data are aggregated at the national level, it is not possible to identify the data on adolescents. HMIS tend to focus on children less than 5 years of age and women of reproductive age, 15–49 years of age. Even in high income countries where HMIS are better developed, the data are frequently not sufficiently disaggregated by age to be able to focus on the adolescent age group, 10–19 years of age, and the subgroups of 10–14 and 15–19 years of age (WHO, 2014a). In addition, data on quality of care, even if they exist, often lack a focus on adolescent-specific elements of quality. Countries that have made progress in measuring the quality of health services for adolescents, based on nationally developed standards, have shown greater utilization of improved quality services.

health-care providers and support staff to use data for action planning and implementation. Improvement is assigned to individuals or a team, any needed training is provided, and information management or other resources are made available. Once an improvement initiative is planned, data are collected to demonstrate that the planned change was actually implemented and was an improvement. Staff motivation to participate in quality improvement may depend on a number of factors, including factors outside the control of facility managers or health systems. However, actions such as supportive supervision or reward and recognition of highly performing staff will help drive a culture that engages in health improvement initiatives.

Intent of Standard 7 This standard, therefore, stresses the importance of the facility’s actions to collect, analyse and use data on cause-specific service utilization and quality of care, disaggregated by age and sex to support quality improvement (see also Standard 8). To monitor equity, it might be necessary to disaggregate data by other important characteristics such as school enrolment or marital status (see Standard 6). However, it has been reported that asking an adolescent about, for example, marital status might, in some cultures, be perceived as a barrier to service use, and grounds to deny services to unmarried adolescents. The advantages and disadvantages of collecting information on certain socio-economic characteristics should be carefully weighed. The facility understands that aggregate data are an important part of the facility’s performance improvement activities; it provides a profile of the facility over time and allows benchmarking and the comparison of the facility’s performance with the performance of other similar facilities. For example, dissemination of good practices and lessons learnt could be organized at local, subnational and national review meetings. The aggregation and analysis of data and information and planning of subsequent improvements frequently requires knowledge and skills that most staff do not have or do not use regularly. Thus, staff involved in these processes need to be provided with the training and tools to manage, display, and report data and information on adolescents in a useful and informative manner. They also need appropriate technological support. Mechanisms are in place not only to support data collection and analysis, but also to support

©DARO SULAKAURI/ADB

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 15

Standard 8 – Adolescents’ participation Adolescents are involved in the planning, monitoring and evaluation of health services and in decisions regarding their own care as well as in certain appropriate aspects of service provision.

Rationale for Standard 8 Adolescents have the right to participate in decisions that affect their lives. The meaningful involvement of adolescents is an integral component of effective adolescent health care (Ambresin A-E et al., 2012). It is essential that their involvement is encouraged and supported by facility staff. There are a number of ways that adolescents can be involved, all of which can influence both the quality of services provided as well as health outcomes. Adolescents have important contributions to make in the policy-making, planning, implementation and monitoring of services provided in the community. Furthermore, if given the opportunity and empowered and trained, adolescents could be effective peer educators, counsellors, trainers and advocates. Adolescents usually have the best knowledge about their own lives and their needs, and they have the capacity to identify approaches or solutions that will best adapt a health-care solution or management option to their personal circumstances. Ignoring

adolescent views regarding their own care can lead to disengagement (e.g. discontinuation of a treatment), and loss to follow-up. In turn, upholding adolescents’ participation in their own care supports the provision of sustainable, acceptable, locally appropriate and more effective solutions, which ensures that more adolescents will seek and remain engaged in care.

Intent of Standard 8 This standard emphasizes three important areas for adolescents’ participation. First, it highlights adolescents’ participation in the planning, monitoring and evaluation of health services. Second, it stresses adolescents’ participation in decisions regarding their own care. Third, it emphasizes adolescents’ participation in certain aspects of service provision. Health-care providers have an obligation to make sure that opportunities are available for adolescents to exercise these rights. To ensure adolescents’ participation in the planning, monitoring and evaluation of health services, the facility regularly solicits adolescents’ perceptions of its services (see also Standards 6 and 7). Including adolescents in the governance structure of the facility is one way to understand their perceptions of its services. In this role,

©CURT CARNEMARK/WORLD BANK

16 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

participants will be limited in number, thus, it will be equally important to solicit this information from other agencies and organizations in the community (see also Standard 2). In addition, the perceptions of current and potential adolescent clients in the community are very important. Solicitation can be through individual interviews, focus groups, surveys, or other means, and is done on a regular basis. The facility has a process to receive, analyse, and use this information to influence its programmes and services. Adolescents have the right to participation (see Glossary) in the processes of their own care. Unless the adolescent lacks decision-making capacity, or the decision-making capacity is delegated by law to a third party, the adolescent can make decisions about all aspects of care, including refusing care.1 The facility supports and promotes adolescent involvement in all aspects of care by developing and implementing policies

and procedures to enable an informed choice (see Glossary). A choice made by an adolescent regarding elements of his/her care is a result of adequate, appropriate and clear information in order to understand the nature, risks and alternatives of a medical procedure or treatment and their implications for health and other aspects of the adolescent’s life (see also Standard 4). In some situations a documented consent for a procedure or treatment is required (see informed consent in the Glossary). The facility has policies and procedures on how to handle an informed consent, and makes sure the providers know and respect them. Finally, the facility engages adolescents in certain aspects of service delivery such as peer education, counselling, training and advocacy. In order to participate in a meaningful way, adolescents should be empowered and trained to do so effectively.

Measurable criteria for Standard 8 Input 71. The governance structure of the facility includes adolescents. 72. There is a policy in place to engage adolescents in service planning, monitoring and evaluation. 73. Health-care providers are aware of laws and regulations that govern informed consent, and the consent process is clearly defined by facility policies and procedures in line with laws and regulations. Process 74. The health facility carries out regular activities to identify adolescents’ expectations about the service2 and to assess their experience of care, and it involves adolescents in the planning, monitoring and evaluation of health services. 75. Health-care providers provide accurate and clear information on the medical condition and management/ treatment options,3 and explicitly take into account the adolescent’s decision on the preferred option and follow-up actions. 76. The health facility carries out activities to build adolescents’ capacity in certain aspects of health-service provision.4 Output 77. Adolescents are involved in planning, monitoring and evaluation of health services. 78. Adolescents are involved in decisions regarding their own care. 79. Adolescents are involved in certain aspects of healthservice provision.

1

A WHO guideline recommends, for example, the provision of sexual and reproductive health services, including contraceptive information and services, for adolescents without mandatory parental and guardian authorization/notification, in order to meet the educational and service needs of adolescents (WHO, 2014b). This may include adolescents’ perceived health-care needs and adolescents’ opinions on what services should be provided, as well as aspects of organization (e.g. working hours), provider-related aspects (e.g. strong preference for male or female provider) and other aspects. For each option, evidence-based information on advantages, disadvantages and consequences should be provided; communication with the adolescent is in a language and format he/she can understand. For example, peer education. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 17

2

3

4

IMPLEMENTATION The implementation of standards has two aspects. The first is what to do to implement – that is, what are the actions in the facility and beyond that need to be undertaken in order to meet the standards. The second is how to implement – that is, the planning and management of the implementation process. • governance, so that policies are in place that respect, protect and fulfil adolescents’ rights in health care and national health management information systems that provide the evidence base for decision-making; • financing, so that allocation of resources and purchasing services is done in a way that meets the need of adolescents; • strengthening workforce capacity, so that health-care providers have the necessary competencies to implement the standards; • ensuring that the necessary drugs, supplies and technology are available so that the functioning of the facility is seamless. Therefore, apart from actions in the facility and community, national- and district-level,1 actions will be necessary in each of the health system pillars in order to enable facility staff and managers to implement the standards and their criteria (Table 1). A detailed implementation guide is provided in Volume 2.

Implementation plan A standards-driven approach to improve the quality of health-care services for adolescents should be embedded in systemic efforts to strengthen the health sector’s response to adolescent health. As outlined in the WHO report Health for the world’s adolescents: a second chance in the second decade, developing and implementing national quality standards and monitoring systems is just one part of the transformation that health systems need to undergo in order to better respond to adolescent health and development needs. Improving the quality of care at mainstream primary and referral level facilities cannot succeed without strengthening all pillars of the health system:

©NIK NEUBAUER

1

The subnational political-administrative units in countries vary, and may include states, regions, provinces, districts or zones. For the purpose of this guide we use the term district to indicate a subnational administrative unit, while in each case the equivalent will depend on specific country.

18 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Table 1. Implementation guide National-level actions Review laws, policies and systems, and modify existing ones if necessary, in key areas: provision of a comprehensive package of services, financial protection of adolescents, confidentiality, age of consent, equity, participation, reorganization of services to make them welcoming for adolescents, health management information systems Communicate national laws and policies, and latest revisions, to district managers and request district level actions Advocate with district managers to ensure their ownership and support for key policies Advocate with other sectors and wider society to ensure their support for key policies Develop or review, as appropriate, norms, standards and standard operating procedures (SOPs), and make them known and available in the districts Develop or review, as appropriate, information and training materials, practice guidelines and other decision support tools in adolescent health care Ensure an adolescent health focus in national reports Conduct data synthesis, monitoring and evaluation activities at the national level and use national data to stimulate local actions Governance 1

District-level actions Communicate national laws and policies, and latest revisions, to facility managers, and demand facility-level actions Advocate with facility managers to ensure their ownership and support for key policies Advocate with other sectors and wider society to ensure their ownership and support for key policies Support facility managers to implement key policies, and to translate them into facility SOPs Ensure the availability of information and educational materials at the district level Ensure an adolescent health focus in district reports Conduct data synthesis and monitoring and evaluation activities at the district level and use national and district data to stimulate local actions

Facility-level actions1 Communicate national laws and policies, SOPs, and latest revisions, to facility staff Identify community resources and build partnerships for advocacy and service provision for adolescents Advocate with facility staff, other sectors’ services and the wider community to ensure their ownership and support for the implementation of key policies Develop or adapt, as appropriate, local SOPs to implement key policies Supply facility staff with information and training materials, practice guidelines and other decision support tools Ensure an adolescent health focus in facility reports Monitor the implementation of quality standards in the facility, and use data to stimulate actions

These actions are facility-led, but some of them happen in and with the community. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 19

National-level actions Define core competencies in adolescent health and development and develop and implement competency-based training programmes in pre-service and continuous professional education Set up a system for supportive supervision in adolescent health care Ensure an adolescent health focus in job descriptions and policies on skill mix1 Workforce capacity Financing 1

District-level actions Plan capacity-building activities at the district level Conduct capacitybuilding activities in adolescent health care and support facility managers in doing so Implement a system of supportive supervision in adolescent health care at the district level Ensure that decision support tools are available in health-care facilities and providers know how to use them

Facility-level actions Plan capacity-building activities for facility staff Ensure staff participation in continuous professional education in adolescent health care and in supportive supervision Ensure that decision support tools are available in health-care facilities Conduct capacitybuilding activities Plan staff profile and manage staff time to enable the implementation of key policies Inform district officials about facility needs to enable allocation of funds for key activities

Negotiate allocation of funds from the national budget to ensure the provision of a comprehensive package of services to adolescents Finance continuous professional education activities Finance quality improvement initiatives in adolescent health care Finance the production of information and education materials for adolescents and community members

Allocate funds for the provision of a comprehensive package of services in adolescent health care Finance continuous professional education activities Finance quality improvement initiatives in adolescent health care Finance the production of information and educational materials for adolescents and community members

In the long run, every health-care provider should have core competencies in adolescent health and development, acquired through a combination of pre-service training and continuous professional education. In the interim, there should be at least one health-care provider in the facility trained in adolescent health care to ensure the necessary skill mix of facility’s team.

20 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Implementation process The actions outlined in the implementation guide need buy-in at different levels of the health system by various stakeholders before standards are developed and implemented. Developing a shared understanding of adolescent health and establishing the basis for addressing adolescents within the national health policies and strategies are a prerequisite for implementation of the standards. The figure below shows the main steps in the implementation process.

in 2013 from the WHO Country Planning Cycle Database, 84% of the policies included some attention to adolescents. However, in most cases, the focus was on sexual and reproductive health (including HIV/AIDS), while areas such as mental health, violence and injuries, substance use and substance use disorders, chronic illness, nutrition or physical activity, were less frequently included. Successful implementation of the global standards requires a participatory process involving key stakeholders to create a shared understanding of the whole range of needs of adolescents beyond a limited focus on sexual and reproductive health. In addition, it requires a shared understanding of the specific contribution that health-care services can make for priority health and development problems. The WHO report Health for the world’s adolescents is a resource that can inform senior and mid-level staff of ministries of health, NGOs and the range of health sector partners responsible for developing, implementing and supporting policies and programmes that contribute to adolescent health. It might be helpful to form a national working group for this purpose, or use an existing one, including policy-makers, ministry of health

Develop a shared understanding of adolescent health and the need to improve the quality of healthcare services Grounding the quality improvement initiative in national policies and strategies may make it more likely that it will receive both moral and material support of decision-makers in the government and in international organizations. Many countries have realized the importance of explicit attention to adolescent health within national health policies, strategies and plans. Among the national health policy documents from 109 countries retrieved

Fig. 2 Steps in the process of implementation of the global standards Develop a shared understanding of adolescent health and the need to improve the quality of health-care services within national policies and strategies within quality improvement mechanisms and initiatives

Conduct a situation analysis to inform the adaptation of the global standards and their implementation plan

Conduct preparatory work to facilitate implementation

Implement actions at facility, district and national levels to meet the standards

Monitor and evaluate the implementation of the standards

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 21

programme managers, technical experts, service providers and community representatives, including adolescents themselves, as well as other interested groups such as international and national NGOs, the United Nations and other internal and external development partners. The meaningful involvement of adolescents in this process is crucial. Adolescents have the capacity to identify approaches or solutions that will best accommodate their personal circumstances or needs. It is essential that policy-makers and health-care providers encourage and support adolescents’ involvement in policy formulation and their own health care. In order to participate in a meaningful way, adolescents should be given opportunities, empowered and trained to acquire the necessary skills to lead advocacy efforts and policy- and decision-making processes in the country. The creation of the shared understanding of adolescent health, and the need to improve the quality of health-care services, should not be seen, however, as a one-off event or in isolation from other steps of the process. Even though a national consultation and an informal meeting – or a series of each – might be necessary to start or to build on an existing process, shared understanding will be furthered through the situation analysis, national adaptation of the global standards and the implementation process.

risk factors and social determinants. This will largely inform the content of the package of services that will need to be offered as part of the implementation of standards. (ii) help-seeking and health care-seeking practices of adolescents, and barriers to the provision and utilization of health services by adolescents. This will largely inform the domains of the standards and the need for adaptation of the global standards. (iii) by whom – and where – health services are currently provided to adolescents, and which health service providers within the health system of the country are best placed to ensure the largest coverage with the required package of services. This will largely determine what types of facilities are the priority for implementation. (iv) what are the experiences within the country in applying quality improvement principles and practices in public health programmes. This will help apply lessons learnt from initiatives in the country that have worked to improve the quality of health service provision and to increase health service utilization by any population group to the adolescent population. In addition, it will inform how to better institutionalize the implementation of the standards for adolescent health care within existing policies and procedures. Adolescents from key populations face greater HIV risk than the general population and have specific health-related needs. Accordingly, for the response to be appropriate, acceptable and most effective, these risks and needs must be examined locally, and local adolescent members of key populations must be consulted and actively involved in the situational analysis (WHO, 2014c). Key population size and distribution vary from place to place. To determine the required scale of the response, the appropriate balance among different interventions and where interventions should be targeted, it is important to appreciate the size and distribution of adolescent members of key populations, among other factors. Whereas data should guide the response, lack of data is not a reason to stop or not initiate a response to HIV among key populations and their adolescent members. When undertaking information-gathering exercises, it is important to strictly maintain privacy, confidentiality and the security of the information collected. If the safety and the human rights of adolescents from

Conduct a situation analysis to inform the national adaptation of the global standards and their implementation plan The analysis of national standards from 25 countries showed that despite variations in countries’ contexts and priority health problems, national standards and criteria largely covered similar areas. It means that overall, global standards are likely to capture the quality problems in service delivery in any given country. However, specific problems and needs will exist, and they need to be identified in order to make a proper adaptation of global standards to the country context. The situation analysis – through discussions with key informants in the ministry of health, NGOs, academic institutions, international agencies and adolescents themselves, and a desk review of published papers and reports – should summarize key issues such as: (i) priority health and development problems of adolescents in terms of health outcomes, health-related behaviours, protective and

22 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

key populations cannot be protected, collection of certain data, such as mapping where adolescents from key populations congregate, is better avoided (WHO, 2014c).

• informing key stakeholders at the national, districts and facility levels who could help or hinder the implementation of the initiative. It may also be necessary to manage the expectations of those involved in the implementation. For example, different stakeholders may have different expectations about where the standards will be implemented – in which facilities, and how many. Expectations also may differ with regard to the need for piloting the implementation, geographic areas for initial implementation and expansion, or the desired pace of scaling up. It is important to clarify what these expectations are and to ensure that they are considered in the design of the implementation process. While piloting the implementation of standards is warranted in order to learn lessons before nation-wide scale-up, it should be understood that the ultimate aim is that every health-care facility meets the required standards. The WHO guide Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up (2011) contains 12 recommendations to ensure that pilot or other programmatic research is designed in ways that lead to lasting and larger-scale impact.

Adapt global standards as per the findings of the situation analysis The situation analysis might reveal that changes to the global standards and/or their criteria are required in order to better reflect the situation in the country. For example, some of the criteria might be considered not essential, or new standards might be added to reflect a problem area that is currently not adequately captured by the global standards. In this case, the technical working group will need to develop input, process and output criteria for the new standards. They will also need to be sure that the new criteria are not redundant with existing criteria of other standards. It should be decided which of the new criteria should be regularly monitored, and what changes are required in order to do so in the standards’ monitoring tools (see Volume 3). Similarly, if adaptations concern criteria within any given standards (e.g. added, deleted or modified criteria), it should be decided what implications it has for the monitoring process and monitoring tools. The country implementation plan might need to reflect changes that were made in the process of the national adaptation of the global standards. For example, if in the national adaptation process new standards or criteria within standards were added, it might be necessary to identify and implement corresponding actions at the national, district and facility level.

Implement actions at national, district, facility and community levels to meet the standards Actions at the national, district, facility and community levels are outlined in Table 1, and a detailed guide is provided in Volume 2. It is important to appreciate that facility-level actions may be initiated before the national- and districtlevel actions are completed. Improving policies and other actions at the national level takes time, and there is no reason to delay facility-level actions that do not require national or district level support and can be accomplished locally.

Conduct preparatory work to facilitate the implementation Before beginning the implementation, certain actions will be necessary such as: • official adoption/clearance of the standards by relevant authorities; • identifying the responsible team/unit that will drive the national standards-driven initiative in the country; • identifying funds to implement actions stipulated in the implementation plan; • deciding on the sequence and scale of implementation;

Monitor and evaluate This guide contains a set of tools to conduct quality and coverage measurement surveys to collect data about compliance with standards. The tools are designed to gather information about standards’ criteria from key informants (facility managers, health-care providers, support staff, adolescent clients, adolescents in the community, gatekeepers in the facility, gatekeepers in the community), as well as from direct observation of the care process (Volume 3). Facility compliance with quality standards will be reflected in the

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 23

aggregate scores per each standard (out of 100%). Volume 4 includes an explanation of how the aggregated score is calculated. There are several steps to consider in the planning, implementation and analysis of the results of the quality and coverage measurement surveys: determining the scope of the assessment, forming and training the assessment team, planning the time and resources, pre-testing the data collection instruments, collecting, scoring, summarizing and disseminating data, and planning for improvements. These steps are described in detail in the WHO publication Quality assessment guidebook: a guide to assessing health services for adolescent clients (2009). Tracking the progress in the standards’ implementation should happen at three levels: facility, district and national.

• criteria that were agreed upon between a number of facilities to enable horizontal comparisons. A good practice is to space out the completion of the questionnaires over the entire implementation period between quality improvement meetings. In Myanmar, for example, the national guidance on service standards for adolescent health care recommends quality improvement meetings every 3–4 months. At the same time it is recommended to interview one or two clients per day rather than try to fill in all 80 questionnaires in one or two weeks before the quality improvement meeting.

Periodic evaluation Evaluation of the implementation of quality standards for adolescent health care is the periodic assessment of the overall process of implementation to inform district- and national-level actions. This includes not only the benchmarking of the performance of individual facilities against the standards, but also the assessment of reasons for under-performance, as well as lessons learnt from champion institutions. For example, if a national survey found that an important proportion of facilities do not meet Standard 7, which requires that the health facility collects, analyses and uses data on adolescents’ service utilization and quality of care, disaggregated by age and sex, one of the underlying reasons might be that data collection and reporting forms, which are endorsed at national level, were not revised accordingly. Evaluations are, therefore, important to identify the support that facility staff and facility managers may need from the national and district levels to improve performance. In addition, if a standard or its criteria no longer reflect a relevant problem or current health-care practice, it should be revised. Evaluations are important, therefore, to identify changing priorities and the need for standards’ revision (see Fig. 2 above). Table 2 summarizes the scope, methods and expected frequency of the standards’ monitoring and evaluation activities at the facility, district and national levels.

Routine monitoring Monitoring of the standards’ implementation should take place as a continual process to inform quality improvement in adolescent health care at the facility level. It can be done by way of self-assessment or external assessments (e.g. monitoring visits from the district). While full-scale assessments that measure all the criteria for each of the standards are desirable, they are resource consuming and can only be performed once every few years. It is important, however, that regular monitoring of quality is performed at the facility level to ensure that corrective actions are timely. For this, some countries have found it practical to select a short list of criteria (e.g. 2–3 criteria per standard) and identify corresponding indicators for routine monitoring (e.g. every 3–6 months), while deciding to monitor the compliance with the entire list of criteria less often. The choice of the criteria for the limited monitoring could be based on a number of considerations, for example: • criteria that are judged as the most essential for standard implementation, or • criteria that address the most problematic areas as shown by the situation analysis and/or a previous assessment, or

24 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Table 2. Examples of activities to monitor and evaluate the implementation of standards Level/expected frequency Routine monitoring Facility/every 3 months Description of the method and scope of the monitoring and evaluation activity Self-assessments using self-assessment tools1 to monitor a short list of indicators on a limited number of priority criteria (e.g. those criteria that scored least in the previous assessment, or criteria that are considered most essential). Questionnaires could be completed routinely or on a weekly basis, and every 3 months data should be analysed and discussed in facility meetings to identify actions for improvements. Focus of the self-assessments may periodically change depending on the progress the facility makes against selected standards and criteria. Supportive supervision sessions by the facility manager using the client-provider interaction tool. Based on the results of selfassessment, the facility manager may identify problematic areas and focus on those during supportive supervision visits. Monitoring visits by district managers to the facility using a short list of indicators on a limited number of priority criteria in priority facilities (e.g. the least performing facilities). The scope of the evaluation is to assess district performance against all standards and criteria, and to assess the status of the implementation of district-level actions.3 A baseline survey before standards implementation might provide useful information for comparison. Depending on the feasibility, the assessment could be done in a representative sample of district facilities, or in all facilities in the district. The information will be gathered through quality and coverage measurement surveys using standards monitoring tools and key informant interviews. Other sources will be used to gather information about the status of the implementation of the districtlevel actions outlined in the implementation plan, reasons for delayed implementation and factors linked to good progress. The scope of the evaluation is to assess national progress against quality standards, and to assess the status of the implementation of national- and district-level actions.4 A baseline survey before standards implementation might provide useful information for comparison. The assessment might be done in selected districts according to defined criteria or in all districts, but within each of the selected districts the assessment should be conducted in a representative sample of facilities. The information will be gathered through quality and coverage measurement surveys using the standards monitoring tools. Key informant interviews and other sources will be used to gather information about the status of the implementation of national- and district-level actions outlined in the implementation plan, reasons for delayed implementation and factors linked to good progress.

Facility/every 3–6 months

District/every 6 months Periodic evaluations District level/ every 2–3 years2

National level/ every 4–5 years

1

The tools that are provided in Volume 3 can be adapted for use in different contexts – be it self-assessments on a limited number of criteria, or external assessments (monitoring visits) by district managers, on a wider, or full, range of standards and criteria. The tools can be equally adapted to develop checklists for supportive supervision. In geographically small countries district-level evaluations might not be necessary, as national-level evaluations might be sufficient. The implementation guide in Volume 2 can be used to develop checklists to assess the status of implementation of districtlevel actions. The implementation guide in Volume 2 can be used to develop checklists to assess the status of implementation of nationaland district-level actions. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 25

2

3

4

KEY REFERENCE DOCUMENTS Ambresin A-E, Bennett K, Patton GC, Sanci LA, Sawyer SM (2013). Assessment of youth-friendly health care: a systematic review of indicators drawn from young people’s perspectives. J Adolesc Health.52(6):670–681. Chandra-Mouli V, McCarraher DR, Phillips SJ, Williamson NE, Hainsworth G (2014). Contraception for adolescents in low and middle income countries: needs, barriers, and access. Reprod Health.11(1):1. Denno DM, Hoopes AJ, Chandra-Mouli V (2015). Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support. J Adolesc Health.56(1S):S22–S41. doi: 10.1016/j. jadohealth.2014.09.012. Nair M, Baltag V, Bose K, Boschi-Pinto C, Lambrechts T, Mathai M (2015). Improving the quality of health care services for adolescents globally: a standards-driven approach. J Adol Health. 57:288–98. Waddington C, Sambo C (2015). Financing health care for adolescents: a necessary part of universal health coverage. Bull World Health Organ.93:57–59. WHO (2010). Quality assessment guidebook: a guide to assessing health services for adolescent clients. Geneva: World Health Organization. WHO (2011a). Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up. Geneva: World Health Organization. WHO (2011b). Making health services adolescent friendly. Geneva: World Health Organization. WHO (2014a) [online]. Health for the world’s adolescents. A second chance in the second decade. Geneva: World Health Organization (http://apps.who.int/adolescent/second-decade/, accessed 4 August 2015). WHO (2014b). Ensuring human rights in the provision of contraceptive information and services. Guidance and recommendations. Geneva: World Health Organization. WHO (2014c). Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization (http://www.who.int/hiv/pub/guidelines/keypopulations/en/, accessed 4 August 2015). WHO (2015a). Core competencies in adolescent health and development for primary care providers. Geneva: World Health Organization. WHO (2015b) [online]. Health systems strengthening glossary. Geneva: World Health Organization (http://www. who.int/healthsystems/hss_glossary/en/, accessed 12 March 2015).

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For more information, please contact: Department of Maternal, Newborn, Child and Adolescent Health (MCA) World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland Tel.: +41 22 791 3281 Fax: +41 22 791 4853 Email: mncah@who.int www.who.int/maternal_child_adolescent/en

ISBN 978 92 4 154933 2



GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A GUIDE TO IMPLEMENT A STANDARDS-DRIVEN APPROACH TO IMPROVE THE QUALITY OF HEALTH-CARE SERVICES FOR ADOLESCENTS

Volume 2: Implementation guide

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A guide to implement a standards-driven approach to improve the quality of health-care services for adolescents

Volume 2: Implementation guide

©CHARLOTTE KESL/WORLD BANK

WHO Library Cataloguing-in-Publication Data Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents. Volume 2: Implementation guide 4 v. Contents: Volume 1: Standards and criteria - Volume 2: Implementation guide - Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards Volume 4: Scoring sheets for data analysis 1.Adolescent Health Services – standards. 2.Quality of Health Care. 3.Adolescent. 4.Data Collection. 5. Health Care Surveys – methods. 6.National Health Programs. I.World Health Organization. ISBN 978 92 4 154933 2 (NLM classification: WA 330)

© World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/ about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland Cover photo: Vancouver Public Library Design by Inís Communication – www.iniscommunication.com

CONTENTS Acknowledgments Abbreviations Introduction Actions at the national level Actions at the district level Actions at facility level v vi 1 2 8 13

©ALLISON KWESELL/WORLD BANK

©SIMONE D. MCCOURTIE/WORLD BANK

iv GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

ACKNOWLEDGMENTS The World Health Organization (WHO) is grateful to UNAIDS and all those who gave technical input into the production of this document. Lead writers: Subidita Chatterjee (independent consultant) and Valentina Baltag (WHO). WHO working group: Paul Bloem, Krishna Bose (formerly WHO), Venkatraman Chandra-Mouli, Charlotte Christiansen (formerly WHO), Jane Ferguson, Nuhu Yaqub.  Peer review (WHO): Anastasyia Dumcheva, (WHO Country Office in Ukraine), Symplice Mbola Mbassi (WHO Regional Office for Africa), Howard Sobel (WHO Regional Office for the Western Pacific). Peer review (UNAIDS): staff members. Peer review (external review group): Regina Benevides (Evidence to Action, United States of America), Doortje Braeken (International Planned Parenthood Federation, United Kingdom), Scott Burnett (loveLife, South Africa), Danielle Engel (United National Population Fund, United States of America), Mychelle Farmer (Jhpiego, United States of America), Bamikale Feyisetan (Evidence to Action, United States of America), Gwyn Hainsworth (Pathfinder International, United States of America), Jari Kempers (Qalys Health Economics, Estonia), Vijay Kumar (Survival for Women and Children Foundation, India), Catherine Lane (United States Agency for International Development, United States of Amercia), Laura Laski (United National Population Fund, United States of America), Galina Lesco (National Resource Centre in YFHS “Neovita”, Republic of Moldova), Ricky Lu (Jhpiego, United States of America), Elizabeth Mapella (Ministry of Health, United Republic of Tanzania), Edgar Necochea (Jhpiego, United States of America), Beth Outterson (Save the Children, United States of America), Elizabeth Saewyc (University of British Columbia, Canada), Olena Sakovych (United Nations Children’s Fund, Ukraine), Susan Sawyer (University of Melbourne, Australia), Kat Watson (International Planned Parenthood Federation, United Kingdom), Sylvia Wong (United National Population Fund, United States of America). Editing: Jura Editorial Services, Gex, France.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS v

ABBREVIATIONS HMIS NGO SOP WHO health management information systems nongovernmental organizations standard operating procedure World Health Organization

vi GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS ©THE WORLD BANK

INTRODUCTION This document is part of the Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health-care services for adolescents. It is one of four volumes published separately, which include: • Volume 1: Standards and criteria • Volume 2: Implementation guide • Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards • Volume 4: Scoring sheets for data analysis This volume, the Implementation guide, provides detailed guidance on identifying what actions need to be taken to implement the standards at the national, district and facility levels. It can be used to develop checklists to assess the status of implementation.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 1

ACTIONS AT THE NATIONAL LEVEL Governance Review laws, policies and systems, and modify existing ones if necessary • Comprehensive package of services: (i) Define the required package of health information, counselling, diagnostic, treatment and care services for adolescents based on up-to-date evidence on mortality, morbidity, health-related behaviours, risk and protective factors and social determinants affecting adolescent health; (ii) review laws and policies and modify them as necessary to enable the provision of the defined comprehensive package of services for adolescents; and (iii) review policies and modify them as necessary to ensure planned transition from child-centred to adultcentred health care for adolescents with chronic conditions that mandates coordination and joint planning between primary care providers and specialists (e.g. between paediatrician and general practitioner). • Financial protection: Design and implement measures of adolescents’ financial protection (e.g. waivers, vouchers, exemptions from or reduced co-payments) so that health services are free at the point of use or affordable to adolescents. • Confidentiality: Review national laws and policies to include provisions on (i) clear and unambiguous indication of situations when confidentiality could be breached (e.g. disclosure of sexual abuse of a minor, significant suicidal thoughts or self-harm or homicidal intent), with whom, and for what reasons; (ii) clear standard operating procedures (SOPs) in situations when confidentiality might be breached due to legal requirements; (iii) clear requirements that in all other circumstances, facility managers, service providers and support staff are to maintain the confidentiality of their adolescent clients; (iv) clear requirements that a consultation with an adolescent client accompanied by parents/ guardians should routinely include time alone with the adolescent; (iv) clear procedures to be followed in the facility to ensure that information

©LUIS ENRIQUE ASCUI/ADB

2 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

•

•

•

•

about clients is not disclosed to third parties, and that personal information including client records are held securely; and (v) requirements for the organization of the physical space of the facility and actions to ensure visual and auditory privacy during registration and during consultation with a service provider. Age of consent: Examine and potentially revise current policies for age of consent in order to (i) reflect current WHO recommendations; (ii) give clear and unambiguous indication of situations when an informed consent is required, the legal age of adolescents’ consent for key clinical situations and procedures, and from whom the consent should be obtained if the adolescent is below the legal age of consent for a given situation/procedure; (iii) adopt flexible policies to allow adolescents in specific groups or situations to be considered “mature minors”; (iv) include SOPs for obtaining informed consent; (v) emphasize that in all cases, whether or not the consent of the parent/ guardian is required, the voluntary, adequately informed, non-forced and non-rushed assent of the adolescent should be obtained; and (vi) communicate that in all situations, whether or not a documented consent by the adolescent is required, adolescents should be given full, unbiased and clear information on the nature, risks and alternatives of a medical procedure or treatment and their implications to enable adolescents’ participation in their own care and the communication of their choices. Equity: Review national laws and policies and modify them as necessary to ensure that they do not restrict the provision of health services to adolescents; make sure that policies state the obligation of facility staff to provide services to all adolescents irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other characteristics. Participation: Review laws and policies and modify them as necessary to ensure that adolescents are involved in planning, monitoring, evaluation and provision of services; ensure that national directive(s) that establish the policy for the governance of health-care facilities make provisions for the inclusion of adolescents in the governance structure. Welcoming services: Review existing policies to include provisions on (i) ensuring convenient operating hours for the local adolescent population and reducing waiting time; (ii) ensuring a welcoming and clean environment (seating area is comfortable and clean, drinking water is available, educational materials are

available, toilets are clean and functioning, surrounding area is clean); and (iii) ensuring privacy at all stages of the process of care. • Health management information system (HMIS): Review the HMIS, including data collection and reporting forms and reporting requirements to ensure that all data (e.g. presenting problem, diagnosis and services provided) on the first 20 years of life are disaggregated by sex and 5-year age groups, and that these data remain disaggregated when they are synthesized at the national level.

Communicate national laws and policies, and latest revisions, to district managers and request district-level actions • Communicate laws and policies, including the latest revisions, on (i) equitable service provision to adolescents and financial protection measures; (ii) the age of consent; (iii) confidentiality; (iii) adolescents’ participation in planning, monitoring, evaluation and provision of services; and (iv) the organization of welcoming services (e.g. optimizing operating hours and waiting time, ensuring privacy, maintaining a clean environment), and request the development of local procedures to implement the policies. • Inform districts about the latest requirements for reporting, and send updated data collection and reporting forms. • Request that districts make display boards with policies and procedures on equitable (including free or affordable) service provision for adolescents and distribute them to facilities. • Inform districts and facilities that the visible display of adolescents’ rights in the health facility is mandatory. • Inform district managers about the package of health-care services that should be made available to adolescents.

Advocate with district managers to ensure their ownership and support for key policies • Communicate the importance of (i) adopting a human rights-based approach in the healthcare of all adolescents, regardless of their socio-economic status; (ii) involving adolescents in designing and assessing health services; (iii) the special role that confidentiality plays in adolescents’ willingness to use services, and the importance of informing them about confidentiality and applying facility procedures to maintain it; (iv) respecting privacy at all stages of the adolescents’ consultation process, and

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applying facility procedures to assure privacy; and (v) planned transition from child-centred to adult-centred health care for adolescents with chronic conditions. Communicate the need for district officials and facility managers to take actions to help inform adolescents about the range of health services that are provided in the facility. Communicate the importance of local actions (e.g. modifying operating hours to meet the needs of specific groups of adolescents) to make services welcoming and accessible. Communicate the need for district officials and facility managers to identify and engage in formal and informal partnerships with key community organizations to increase community support for adolescent use of services. Communicate to district officials and facility managers about the importance of outreach activities that: (i) inform schools, youth and other community organizations about the value of providing health services to adolescents through outreach; (ii) reach vulnerable groups with information and services by trained outreach workers; (iii) reach out to selected groups of adolescents in the community with selected health services (e.g. some aspects of antenatal care) and commodities (e.g. iron and folic acid tablets). Communicate to districts the importance of involving adolescents, including vulnerable groups, in the planning, monitoring and evaluation of health services, as well as in certain aspects of health-service provision (e.g. outreach health education, counselling and training). Communicate the importance of routine information from districts on cause-specific utilization of services by adolescents, and the role of an adolescent health focus in district and facility-based registers. Communicate the importance of routine facilitylevel assessment of the quality of services for adolescents and periodic evaluations at the district level.

• Raise awareness in national meetings and in the mass media about national policies on adolescents’ financial protection and other policies that protect adolescents’ rights to receive quality services irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other characteristics. • Communicate about adolescents’ rights to confidentiality and privacy in the mass media and in meetings with national-level representatives of other sectors (e.g. education) and civil society institutions. • Inform the wider community about the package of health-care services that should be made available to adolescents.

Develop or review, as appropriate, norms, standards and standard operating procedures and make them known and available in the districts • Adopt national standards for quality health-care services for adolescents. • List the health services from the defined package that are to be provided to adolescents within the health facility and in the community, and develop guidelines/SOPs on how to implement the package. • List the health services that are to be provided at each level of care (e.g. primary level, secondary level and referral level), and develop SOPs for the referral system to ensure compliance.

Develop or review, as appropriate, information and training materials, practice guidelines and other decision support tools in adolescent health care • Develop or adapt materials from locally or internationally available information and educational materials for adolescents, parents, guardians and other community members and organizations to inform them about the value of providing health services to adolescents. Liaise with nongovernmental organizations (NGOs) working on adolescent health issues in the country to explore whether the informational/ educational materials they produce could be disseminated to the districts (after adaptation, if required). • Develop or adapt materials using ageappropriate visual and audio aids on key medical conditions, their management and treatment options for adolescents and send them to the

Advocate with other sectors and wider society to ensure their support for key policies • Communicate the rationale for providing health services to adolescents in the mass media and in meetings with national-level representatives of other sectors (e.g. education) and civil society institutions.1

1

For example, nongovernmental organizations or religious bodies.

4 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

districts. Liaise with NGOs providing healthcare services to adolescents in the country to explore whether the materials they produce on selected conditions could be disseminated to the districts (after adaptation, if required). • Develop or adapt evidence-based decision support tools (guidelines, protocols, algorithms, job aids) for adolescent health-care conditions and situations as required by the defined package of services. • Ensure that these decision support tools are included in teaching/learning materials and activities. • Develop or adapt tools for supportive supervision and distribute them to districts and facility managers.

Ensure an adolescent health focus in national reports • Ensure that national reports on cause-specific utilization of services include a focus on adolescents. • Ensure that other national reports (e.g. Demographic and Health Surveys, Behaviour Surveillance Surveys, quality of care evaluations) have a focus on adolescents.

• Develop and endorse tools to monitor the implementation of national standards for quality health-care for adolescents. • As part of periodic nationwide evaluations of the implementation of standards: (i) analyse national data on adolescents’ experience of care; (ii) analyse national data on vulnerable adolescents’ experience of care; (iii) evaluate compliance with evidence-based guidelines and protocols and the impact on adolescent health. Provide feedback to districts in each of these areas and support them in taking corrective actions. • Conduct periodic evaluations of equity in adolescent health care, provide feedback to districts and facilities, and implement nationallevel corrective actions to increase equity. • Set up a system to reward and recognize highly performing districts, facilities, health-care providers and support staff, and inform districts. Communicate to district officials the importance of recognizing and rewarding well-performing facilities and staff, and do so using a combination of extrinsic (e.g. financial rewards), and intrinsic rewards (e.g. professional education activities).

Workforce capacity Define core competencies1 in adolescent health and development and develop and implement competency-based training programmes in pre-service and continuous professional education • Define the core competencies required by the service providers in adolescent health and development in key areas (communication, basic concepts in adolescent health and development, laws and policies that affect adolescent health-care provision, quality standards for health-care services, technical competencies regarding clinical care in specific clinical situations). • Set up a system for continuous professional education in adolescent health care including a combination of traditional learning methods (e.g. face-to-face trainings, seminars, casereviews, participation in conferences) with innovative ways to access teaching expertise and materials (e.g. e-learning, self-learning by accessing electronic databases). • Develop and implement competency-based training programmes in adolescent health and development in pre-service and continuous professional education in adolescent health

Conduct data synthesis, monitoring and evaluation activities at the national level and use national data to stimulate local actions • Communicate to district officials (i) the importance of using data for action planning and implementation of quality improvement initiatives; (ii) the requirements for district-level responsibilities in monitoring and evaluating the implementation of standards (e.g. monitoring visits to facilities and periodic district-level evaluations). • Communicate to districts who are the vulnerable group(s) of adolescents based on national data and encourage district- and local-level analysis of vulnerable groups of adolescents. • Issue a directive that: (i) establishes that self-assessments of the quality of care for adolescents are a mandatory part of the routine functioning of primary care facilities, and includes recommended timing and various roles and responsibilities; (ii) includes the provision that identification of adolescents’ expectations about the service and assessment of their experience of care are part of the self-assessment. 1

See Core competencies in adolescent health and development for primary care providers at http://apps.who.int/iris/ bitstream/10665/148354/1/9789241508315_eng.pdf?ua=1. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 5

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information, counselling, diagnostic, treatment and care for priority conditions. Ensure that a human rights-based approach to adolescent health care, including preventing discrimination, is addressed in both pre-service and continuous professional education training, handbooks and training materials. Request that districts regularly identify training needs in core competencies in adolescent health and development at the district level and conduct competency-based in-service trainings in adolescent health. Ensure that training and orientation materials on adolescent health and development and a human rights-based approach to adolescent health care are available at the district level. Ensure that training and orientation on data collection and analysis to inform quality improvement actions are available at the district level. Organize trainings on the safe use of equipment, or support district managers to organize such trainings.

deploy staff to facilities to ensure the necessary skill mix.

Financing Negotiate allocation of funds from the national budget to ensure the provision of a comprehensive package of services to adolescents • Work with the ministry of finance so that budget allocations are adequate to enable the provision of the defined package of adolescent healthcare services. • Make the national package of adolescent health services an instrument to guide purchasing decisions and benefit packages, with due attention to preventive services.

Finance continuous professional education activities • Allocate funds to ensure continuous professional education activities in adolescent health and development at the district level. • Allocate funds for capacity building, as part of the continuous professional education of facility managers and health-care providers, in using decision support tools for various adolescent health-care conditions and situations as required by the defined package of services. • Allocate funds to support the activities necessary to implement the system for supportive supervision in adolescent health care (e.g. training of trainers, travels). • Allocate funds for printing and other dissemination means of decision support tools.

Set up a system for supportive supervision in adolescent health care • Set up a system for supportive supervision in adolescent health-care (including peer, supervisor and external assessment) and emphasize the educational, problem-solving and non-punitive nature of it. Ensure that supportive supervision is linked to priorities for improvement as identified during the monitoring of the implementation of standards and that feedback to staff is provided. • Make sure the system of supportive supervision is extended to community health workers and other outreach workers involved in providing information and services to adolescents.

Finance quality improvement initiatives in adolescent health care • Allocate funds to implement national quality standards,2 and to implement reward and recognition actions of highly performing districts. • Make funds available to enable districts to support health-care facilities in implementing actions to improve the quality of health care of adolescents, based on findings of self-assessments.

Ensure an adolescent health focus in job descriptions and policies on skill mix1 • Include competencies in adolescent health and development in job descriptions as relevant, and ensure that objectives, responsibilities, authority and lines of accountability within job descriptions include a focus on adolescents. • Define the skill mix in adolescent health care of teams at different levels of the health-care system, identify district staffing needs, and

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In the long run, every health-care provider should have core competencies in adolescent health and development, acquired through a combination of pre-service training and continuous professional education. In the interim, there should be at least one health-care provider in the facility trained in adolescent health care to ensure the necessary skill mix of facility’s team. That is, funds to implement the actions outlined in this implementation guide.

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6 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Finance the production of information and education materials for adolescents and community members • Communicate with districts to identify their needs for information and education materials for adolescents and community members, and allocate sufficient funds for their production.

Drugs, supplies and technology Develop or review, as appropriate, checklists for basic amenities, drugs, supplies and technology • Endorse, and send to districts, a checklist for basic amenities such as electricity, water, sanitation and waste disposal that should be available in the facility to enable the provision of the defined package of services. • Prepare lists, and send to districts, of medicines and supplies that facilities need in order to provide the defined package of services. • Prepare lists, and send to districts, of equipment that facilities need to have in order to provide the defined package of health services, and stipulate requirements for maintenance and safe use.

and support districts in addressing those deficiencies in a timely manner. • Work with district officials to determine shortages in the stocks of medicines and supplies that are required to provide the defined package of health services, and ensure timely resupply. • Work with district officials to determine gaps in the availability of the equipment required to provide the defined package of health services, and ensure timely supply and maintenance.

Advocate with districts to ensure the equitable use of the drugs, supplies and technologies in the care of adolescents • Communicate to district managers the importance of the equitable provision of medicines and supplies, with special regard to adolescent clients, and the importance of taking corrective actions in the event of inequitable use (e.g. denying adolescents certain methods of contraception). • Communicate to district managers the importance of equitable use of medical equipment and technology, with special regard to adolescent clients, and the importance of taking corrective actions in the event of inequitable use (e.g. denying adolescents access to sophisticated equipment).

Work with districts to determine needs in drugs, supplies and technology, and ensure the needs are met • Work with district officials to determine deficiencies in the availability of basic amenities,

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 7

ACTIONS AT THE DISTRICT LEVEL Governance Communicate national laws and policies, and latest revisions, to facility managers, and encourage facility-level actions • Communicate to facility managers laws and policies, including the latest revisions, on (i) equitable service provision to adolescents and financial protection measures; (ii) the age of consent and confidentiality; (iii) adolescents’ participation in planning, monitoring, evaluation and provision of services; and (iv) the organization of welcoming services (e.g. optimizing operating hours and waiting time, ensuring privacy, maintaining a clean environment); and encourage the development of local procedures to implement the policies. • Inform facility managers about the defined package of health information, counselling, diagnostic, treatment and care services for adolescents. • Ensure that facility managers receive the guidelines/SOPs regarding which health services are to be provided to adolescents within the health facility and which in the community. • Ensure that facility managers receive the documents on referral policies within and outside the health sector and the SOPs to implement them. • Inform facility managers about mandatory visible display of adolescents’ rights in the health-care facility. • Inform districts about the latest requirements for HMIS, and send updated data collection and reporting forms. • Ensure that facility managers are aware of the provision in the national policies for the inclusion of adolescents in the governance structure of the health-care facility, and communicate the importance of doing so.

Advocate with facility managers to ensure their ownership and support for key policies • Communicate to facility managers and staff the importance of (i) protecting adolescents’ rights to receive quality services irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other characteristics; (ii) involving adolescents in designing and assessing health services;

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8 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

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(iii) the special role that confidentiality plays in adolescents’ willingness to use services, and the importance of informing them about confidentiality and applying facility procedures to maintain it; (iv) respecting the privacy at all stages of the adolescents’ health care, including during appointments, and of applying facility procedures to assure privacy; and (v) planned transition from child-centred to adultcentred health care for adolescents with chronic conditions. Communicate to facility managers the importance of local actions to help inform adolescents about the range of health services available (e.g. putting up a notice board), and to organize welcoming services (e.g. modifying working hours to meet the needs of specific groups of adolescents). Communicate to facility managers about the importance of outreach activities that: (i) inform schools, youth and other community organizations about the value of providing health services to adolescents through outreach; (ii) reach vulnerable groups with information and services by trained outreach workers; (iii) reach selected groups of adolescents in the community with particular health services (e.g. some aspects of antenatal care) and commodities (e.g. iron and folic acid tablets); (iv) working with NGOs in the community that could engage selected adults or adolescents to provide health services and commodities to adolescents in the community. Communicate the importance of routine information from health facilities on causespecific utilization of services by adolescents, and the role of an adolescent health focus in facility-based registers. Communicate to facility managers the importance of routine facility-level assessment of the quality of services for adolescents.

• Raise awareness in the media about national policies on adolescents’ financial protection and other policies that protect adolescents’ rights to receive quality services irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other characteristics. • Communicate about adolescents’ rights to confidentiality and privacy in mass media, and in meetings with district-level representatives of other sectors (e.g. education) and civil society institutions.

Support facility managers to implement key policies and to translate them into facility SOPs • Work with facility managers to identify which groups of adolescents to reach with services in the community, where to reach them, and what health services and commodities to reach them with. • Support facility managers to increase compliance to SOPs for referrals (e.g. facilitate access through referral linkages to services that are not available locally). • Support facility managers in translating policies on equity and financial protection into local SOPs. • Support facility managers in translating the policies on confidentiality and privacy into local SOPs. • Support facility managers in translating the policy on informed consent into local SOPs. • Make display boards with policies and procedures on equitable (including free or affordable) service provision for adolescents and distribute to facilities. • Encourage facility managers to create local processes for involving adolescents in designing, assessing and providing health services, and to have a plan on how to engage adolescents.

Advocate with other sectors and wider society to ensure their ownership and support for key policies • Communicate the rationale for providing health services to adolescents in meetings with district-level representatives of other sectors (e.g. education) and civil society institutions. • Communicate what health services are provided, where and when they are provided, and how much they cost: (i) in the mass media (where possible); (ii) in meetings with representatives of other sectors (e.g. education) and civil society institutions.

Ensure the availability of information and educational materials at the district level • Arrange for the delivery of information and educational materials obtained from national officials or NGOs to facilities, and/or liaise with NGOs working in the district to explore whether the materials they produce could be disseminated to health-care facilities (after adaptation, if required). • Arrange for the delivery of information materials on key conditions and their management options obtained from national officials or NGOs to facilities, and/or liaise with NGOs in

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 9

the district that provide health-care services to adolescents to explore whether the materials they produce on selected conditions could be disseminated to the facilities (after adaptation, if required).

Ensure an adolescent health focus in district reports • Ensure that district reports on cause-specific utilization of services and quality of care include a focus on adolescents including very young adolescents.1

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Conduct data synthesis and monitoring and evaluation activities at the district level and use national and district data to stimulate local actions • Orient facility managers to the national policy for self-assessment of the quality of adolescent health care, and communicate to facility managers the importance of using data for action planning and implementation of quality improvement initiatives. • Orient facility managers to the importance of identifying adolescents’ expectations about the service and assessing their experience of care as part of facility self-assessment. • Make sure tools for self-assessment, including tools to assess adolescents’ expectations about the service and their experience of care, are known to facility managers, and available in facilities. • Monitor the implementation of policies regarding the provision of the defined package of services for adolescents within the health facility and in community settings and the compliance with SOPs. • Monitor the implementation of referral policies at the district level and compliance with SOPs. • Analyse district data to assess equity in adolescent health care, provide feedback to facility managers and support them in taking corrective actions. • Conduct periodic visits to facilities to monitor the implementation of measures for financial protection of adolescents as stipulated in national laws and policies (e.g. vouchers, exemptions from co-payments). • As part of periodic evaluations of the implementation of standards: (i) analyse district data on adolescents’ experience of care, including the experience of care in subgroups of adolescents (e.g. in vulnerable groups), provide 1

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feedback to facilities and support them in taking corrective actions; (ii) assess compliance with evidence-based guidelines and protocols, provide feedback to facility managers and health-care providers and support them in taking corrective actions. Evaluate the quality of outreach activities in the district and support facility managers in taking corrective actions. Conduct a district analysis of who are the vulnerable groups of adolescents, share this information with facility managers and encourage local analysis to identify vulnerable adolescents in the local communities. Develop and share with facility managers a list of organizations working with adolescents in the district and catchment areas of the district’s health facilities. Take district-level actions to implement the system for reward and recognition of highly performing facilities, communicate to facility managers the importance of recognizing and rewarding well-performing health-care providers and support staff, and do so using a combination of extrinsic (e.g. financial rewards), and intrinsic rewards (e.g. professional education activities).

Workforce capacity Plan capacity-building activities at the district level • Inform facility managers and staff about national policies concerning training in adolescent health and development. • In consultation with facility managers, identify training needs and develop a district plan for health-care provider training in adolescent health information, counselling, diagnostic, treatment and care services. • In consultation with facility managers, identify training/orientation needs and develop a district plan for health-care provider training in humanrights based approaches to adolescent health care. • Work with facility managers to determine staff training needs in safe use of equipment. • Inform facility managers and staff about the availability of trainings in key areas of adolescent health and development (e.g. management of priority conditions, human rights-based approaches to adolescent health care), and their schedule.

Very young adolescents includes those 10–14 years old.

10 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Conduct capacity-building activities in adolescent health care and support facility managers in doing so • Organize competency-based trainings in key areas of adolescent health and development (e.g. management of priority conditions, human rights-based approaches to adolescent health care) as part of continuous professional education.1 • Ensure that training and orientation materials on human rights-based approaches to adolescent health-care are available to facility managers. • Conduct training/orientation for facility managers on quality improvement in the field of adolescent health care, including using data collection tools, data analysis and action planning. • Provide orientation to facility managers on using new forms and reporting. • Support facility managers to conduct trainings for outreach workers in adolescent healthrelated topics (e.g. allocate funds for trainings, develop training materials). • Sensitize facility managers on the importance of supporting health-care providers and support staff to respect the rights of adolescents to information, privacy, confidentiality, and of health care that is provided in a respectful, nonjudgemental and non-discriminatory manner. • Organize trainings in the safe use of equipment.

• Distribute decision support tools (guidelines, protocols, algorithms, job aids) to health-care facilities, and organize trainings.

Financing Allocate funds for the provision of a comprehensive package of services in adolescent health care • Allocate, or use funds allocated at the national level, to enable district facilities to provide the defined package of health-care services to adolescents.

Finance continuous professional education activities • Allocate funds, or use funds allocated at the national level, to conduct competency-based trainings and other continuous professional education activities in adolescent health and development at district level. • Allocate funds, or use funds allocated at the national level, for printing and other dissemination means of decision support tools to facilities. • Allocate funds, or use funds allocated at the national level, for in-service training of healthcare providers in using decision support tools for various adolescent health-care conditions and situations as required by the defined package of services. • Allocate funds or use funds allocated at the national level, to conduct trainings of facility managers on how to provide supportive supervision in adolescent health care to healthcare providers and support staff.

Implement a system of supportive supervision in adolescent health care at the district level • Support facility managers to implement a system of supportive supervision in the functioning of the health-care facility. • Encourage facility managers to prioritize the need for supportive supervision based on the findings from the self-assessments of the quality of health-care services in the facilities. • Distribute tools for supportive supervision to facility managers.

Finance quality improvement initiatives in adolescent health care • Allocate funds, or use funds allocated at the national level, to support facilities to implement actions to improve the quality of health care to adolescents based on findings of selfassessments or external assessments. • Allocate funds, or use funds allocated at the national level, to reward and recognize highly performing facilities, health-care providers and support staff.

Ensure that decision support tools are available in health-care facilities and providers know how to use them • Liaise with facility managers to conduct periodic assessments of health-care providers’ needs for decision support tools, and inform national authorities about priority areas.

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This depends on the country, as organizing and conducting trainings might be a responsibility of national or district authorities, or both. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 11

Finance the production of information and educational materials for adolescents and community members • Communicate with facilities to identify their needs for information and education materials for adolescents and community members, and allocate sufficient funds, or use funds allocated at the national level, for their production.

Drugs, supplies and technology Send checklists for basic amenities, drugs, supplies and technology to facility managers • Give facility managers the list of basic amenities that facilities need to have to provide the defined package of health services. • Give facility managers the list of medicines and supplies that facilities need to have to provide the defined package of health services. • Give facility managers the list of equipment, with maintenance and safe use requirements, that the facility need to have to provide the defined package of health services.

• Work with facility managers to determine what quantities of medicines and supplies are required on a monthly/quarterly basis. • Work with facility managers to determine what equipment and maintenance are required on a monthly/quarterly basis. • Work with national officials to obtain the equipment and maintenance services required by the district in a timely manner. • Work with national officials to obtain the medicines and supplies required by the district in a timely manner. • Work with national officials to estimate the basic amenities required by the district and ensure that they are put in place in a timely manner.

Advocate with facility managers to ensure the equitable use of the drugs, supplies and technologies in the care of adolescents • Communicate to facility managers the importance of equitable use of medicines and supplies with special regards for adolescent clients, and the importance of taking corrective actions in the case of inequitable use (e.g. denying adolescents certain methods of contraception). • Communicate to facility managers the importance of equitable use of medical equipment and technology, with special regards for adolescent clients, and the importance of taking corrective actions in the case of inequitable use (e.g. denying access to sophisticated equipment).

Work with facility managers to determine the facility’s needs in drugs, supplies and technology and ensure that the needs are met • Work with facility managers to determine what basic amenities are required (one time or recurring).

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12 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

ACTIONS AT FACILITY LEVEL Governance Communicate national laws and policies, standard operating procedures, and latest revisions, to facility staff • Managers communicate to facility staff laws and policies, their latest revisions, and recommended procedures on (i) equitable service provision to adolescents and financial protection measures; (ii) informed consent; (iii) confidentiality and privacy; (iv) adolescents’ participation in planning, monitoring, evaluation and provision of services; and (v) the organization of welcoming services (e.g. optimizing operating hours and waiting time, ensuring privacy and maintaining a clean environment); (vi) the planned transition from child-centred to adult-centred health care for adolescents with chronic conditions. • Managers make available in the facility printed copies of national laws and policies concerning adolescents’ financial protection and other measures for equitable service provision. • Managers ensure that the guidelines/SOPs regarding which health services are provided in the health facility and/or in community settings are in place and known to staff. • Managers ensure that service providers and support staff are aware of the referral policy within and outside the health sector and the SOPs to implement it. • Managers work with health-care providers and local services within and outside the health sector to develop referral protocols to locally available services. • Managers work with staff, community members and community organizations to identify vulnerable adolescents in their communities, and make sure that facility staff is aware of these groups. • Managers work with service providers and support staff to develop a plan on how to engage adolescents in the planning, monitoring and evaluation of facility services, and service provision. • Managers establish, in consultation with local community(ies) and facility staff, the process of inclusion of adolescent(s) in the governance structure of the facility. • Managers work with service providers and support staff to identify and draw adolescents employed by organizations working with young people or volunteers from the community into the planning, monitoring and evaluation of facility services and service provision. • Managers and health-care providers work with adolescents employed by organizations working with young people or volunteers from the community to draw upon their ideas and suggestions for designing health service provision and to involve them in assessing and providing health services.

Identify community resources and build partnerships for advocacy and service provision for adolescents • Managers identify key community organizations in the catchment area, and engage in formal and informal partnerships with them to increase their support for adolescent use of services, to develop health education and communication strategies and materials and to plan service provision. • Managers inform/share with facility staff the list of key partner agencies and organizations to increase community support for adolescent use of services. • Manager and staff identify NGOs which could engage selected adults and adolescents to provide health services and commodities to adolescents in the community.

Advocate with facility staff, other sectors’ services and the wider community to ensure their ownership and support for the implementation of key policies • Managers communicate to staff the importance of providing evidence-based information to adult visitors about the value of providing health services to adolescents, and monitor these activities as part of supportive supervision and self-assessments. • Managers communicate the importance of, and orient health-care providers and support staff in, respecting the rights of adolescents to information, privacy, confidentiality, participation, and health care that is provided in a respectful, non-judgemental and non-discriminatory manner.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 13

• Health-care providers encourage adolescents to read information on their rights and communicate to them about their rights to confidentiality and privacy. • Managers communicate to health-care providers and support staff the importance of providing services to all adolescents without discrimination. Managers work together with facility staff to raise adolescents’ awareness of financial protection measures and other policies that protect adolescents’ rights to receive quality services without discrimination. • Managers communicate to health-care providers the importance of routine information collection in the health facility on cause-specific utilization of services by adolescents and the role of an adolescent health focus in facilitybased registers. • Managers communicate to facility staff the importance of using data on adolescent healthcare for action planning and implementation of quality improvement initiatives.

into account the needs of specific groups of adolescents. • Managers work with service providers and support staff to determine what could be done to optimize the organization of the physical space of the facility to ensure both visual and auditory privacy in the facility. • Managers work with health-care providers to identify ways to involve adolescents, including vulnerable group(s) of adolescents, in the planning, monitoring and evaluation of health services.

Supply facility staff with information and training materials, practice guidelines and other decision support tools • Even if no materials are obtained from district officials, managers work with healthcare providers to ensure that appropriate clippings from newspapers and magazines, and handmade materials are displayed for information and education for adolescents, parents and other community members. • Managers ensure that information materials on key medical conditions and their management/ treatment options for adolescents are available to health-care providers and used to enable adolescents’ decisions on the preferred options and follow-up actions.

Develop or adapt, as appropriate, local standard operating procedures to implement key policies • Managers ensure the display of boards in the facility about (i) adolescents’ rights; and (ii) policies and procedures on equitable (including free or affordable) service provision for adolescents. • Managers work with service providers and support staff to develop local SOPs including the designation of responsibilities among staff in applying policies on (i) the financial protection of adolescents; (ii) confidentiality; (iii) informed consent; and (iv) planned transition from child-centred to adult-centred health care for adolescents with chronic conditions. • Managers work with service providers and support staff to develop SOPs in applying policies on the equitable provision of services to adolescents and ensure that service providers and support staff know their responsibilities and know the SOPs about equity in adolescent health care (e.g. managers orient newly employed personnel). • Managers work with service providers and support staff to develop SOPs, with assigned responsibilities across health-care providers and support staff, to ensure a welcoming and clean environment and to find local solutions to minimize waiting times. • Managers work with service providers and support staff to determine whether and how the working hours could be modified to take

Ensure an adolescent health focus in facility reports • Health care providers collect data that includes information about adolescents’ age, sex, presenting problem, diagnosis and services provided through facility-level registers. • Managers collate facility data in reports to districts in a way that preserves age- and sexdisaggregated data, including for very young adolescents.

Monitor the implementation of quality standards in the facility and use data to stimulate actions • Managers monitor and evaluate the scope and quality of health education and counselling activities conducted by facility staff (e.g. during the supportive supervision visits and selfassessment surveys). • Managers monitor the implementation of the plan for outreach activities by both healthcare providers and trained outreach workers, evaluate the quality of outreach activities, and take corrective actions as necessary.

14 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

• Managers monitor compliance with local referral protocols and take corrective action as necessary. • Managers monitor the provision of the package of defined services within the health facility. • As part of self-assessment of the quality of care provided in the facility, managers collect facility and community data on compliance with quality standards, provide feedback to facility staff and take corrective actions as necessary, e.g. on aspects such as (i) adolescent clients’ expectations and experience of care with regard to confidentiality, privacy, friendly and nonjudgemental attitude of providers, convenience of working hours and appointment procedures; (ii) equity in adolescent health care, including the expectations and experience of care in subgroups of adolescents (e.g. in vulnerable groups); (iii) compliance of facility practices with evidence-based guidelines and protocols; and (iii) community awareness of, and support for, services provided in the facility. • As part of self-assessment on the implementation of standards, managers monitor whether or not (i) medicine and supplies are equitably used (e.g. identify situations when medicines and supplies were denied for non-medical reasons); (ii) medical equipment and technology are equitably used (e.g. identify situations where adolescents were denied access to expensive technology); and take corrective actions should such events occur. • Managers ensure that tools for self-assessment, including tools to assess adolescents’ expectations about the service and their experience of care, are known to facility staff, available in the facility, and used for monitoring of the quality of health care for adolescents. • In collaboration with facility health-care providers and support staff, facility managers establish a local process to translate the findings of selfassessments into an action plan for quality improvement. • Managers assign roles and responsibilities of staff for the implementation of proposed actions and monitor implementation. • Managers implement facility-level actions for reward and recognition of highly performing staff.

health, adolescent health information, counselling, diagnostic, treatment and care; using decision support tools such as guidelines and protocols for various adolescent health-care conditions and situations; and a human-rightsbased approach to adolescent health care). • Managers inform districts about the training needs of staff in the facility and coordinate with district authorities to ensure that service providers are trained according to their needs. • Managers ensure that staff are trained in the safe use of equipment.

Ensure staff participation in continuous professional education in adolescent health care and in supportive supervision • Managers ensure that supportive supervision activities, such as peer and supervisor assessments, are carried out regularly and are informed by the findings of facility selfassessments of the quality of health-care services in the facility. • Managers communicate to staff that supervisory visits are not merely administrative events, and not intended to be fault-finding or punitive. Rather they are intended to be supportive, educational and aimed at problem-solving. • Managers ensure that the system of supportive supervision is extended to community health workers and other outreach workers involved in providing information and services to adolescents. • Managers ensure that reports from supportive supervision sessions are used to identify needs for improvement. • In collaboration with district officials, managers ensure that staff access continuous professional education activities that include a combination of traditional learning methods (face-to-face trainings, seminars, case-reviews, participation in conferences) and innovative ways to access teaching expertise and materials (e.g. e-learning, self-learning by accessing electronic databases).

Ensure that decision support tools are available in health-care facilities • Managers ensure that service providers have up-to-date decision support tools (guidelines, protocols, algorithms) that cover topics of clinical care in line with the package of services in place in the facility. • Health-care providers inform managers of their need for decision support tools.

Workforce capacity Plan capacity-building activities for facility staff • Managers identify training needs of facility staff in key areas (e.g. communication for adolescent

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 15

Conduct capacity-building activities • Managers provide orientation to relevant staff on using new HMIS forms and reporting. • Managers orient facility staff on the national policy for self-assessment of the quality of adolescent health care and conduct training/orientation for facility staff on quality improvement in the field of adolescent health care, including using data collection tools, data analysis and action planning. • Managers and health-care providers identify and train outreach workers to enable them to conduct health education for adolescents in the community. • Health-care providers train adolescents, including vulnerable adolescents, to provide selected services (e.g. outreach health education, counselling, training).

Drugs, supplies and technology Ensure that basic amenities in health facilities are in place and functioning • Managers have nationally-approved lists of basic amenities that are needed to provide the defined package of health services. • Managers allot responsibility to health-care providers and support staff to review the basic amenities in line with SOPs, and ensure that they are in good order. • Managers organize regular servicing/repairs of basic amenities.

Put in place a system of procurement and stock management of the medicines and supplies necessary to deliver the required package of services • Managers have nationally-approved lists of medicines and supplies that are needed to provide the defined package of health services. • Managers work with health-care providers and support staff to put in place a system to ensure that stocks of medicines and supplies are adequate at all times. • Managers organize regular replenishment of medicines and supplies.

Plan staff profile and manage staff time to enable the implementation of key policies • Managers provide up-to-date job descriptions for health-care providers and support staff and ensure that they understand the objectives, responsibilities, authority and lines of accountability in relation to adolescent health care. • Based on the needs of the local adolescent population, managers identify the skill mix in adolescent health care required in the facility’s health team, and coordinate with district officials to deploy staff to the facility to ensure the necessary staffing profile and skill mix. • Managers plan time for selected staff members to be involved in outreach work. • Managers allocate staff time for training of outreach workers.

Put in place a system of procurement, inventory, maintenance and safe use of the equipment necessary to deliver the required package of services • Managers have lists of equipment, with maintenance and safe use requirements, that is needed to provide the defined package of health services. • Managers work with service providers and support staff to put in place an inventory system to review the availability and state of equipment (e.g. functionality and good order of pieces). • Managers organize regular servicing/repairs of equipment.

Financing Inform district officials about facility needs to enable allocation of funds for key activities • Managers inform district officials about the financial or other support that the facility requires from the district to implement selected actions and use allocated funds to implement them.

Advocate with facility staff to ensure the equitable use of the drugs, supplies and technologies in the care of adolescents • Facility managers communicate to staff the importance of the equitable use of medicines and supplies with special regard to adolescent clients. • Facility managers communicate to staff the importance of equitable use of medical equipment and technology with special regard to adolescent clients.

16 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

©ARNE HOEL/THE WORLD BANK

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 17

© CHARLOTTE KESL/WORLD BANK

For more information, please contact: Department of Maternal, Newborn, Child and Adolescent Health (MCA) World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland Tel.: +41 22 791 3281 Fax: +41 22 791 4853 Email: mncah@who.int www.who.int/maternal_child_adolescent/en

ISBN 978 92 4 154933 2



GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A GUIDE TO IMPLEMENT A STANDARDS-DRIVEN APPROACH TO IMPROVE THE QUALITY OF HEALTH-CARE SERVICES FOR ADOLESCENTS

Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards

©DAVE LAWRENCE / WORLD BANK

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A guide to implement a standards-driven approach to improve the quality of health-care services for adolescents

Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards

WHO Library Cataloguing-in-Publication Data Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents. Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards 4 v. Contents: Volume 1: Standards and criteria - Volume 2: Implementation guide - Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards Volume 4: Scoring sheets for data analysis 1.Adolescent Health Services – standards. 2.Quality of Health Care. 3.Adolescent. 4.Data Collection. 5. Health Care Surveys – methods. 6.National Health Programs. I.World Health Organization. ISBN 978 92 4 154933 2 (NLM classification: WA 330)

© World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/ about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland Cover photo: Edith Kachingwe Design by Inís Communication – www.iniscommunication.com

CONTENTS Acknowledgments Abbreviations Introduction Quality measurement tools Adolescent client exit interview tool Health facility manager interview tool face sheet Observation tool and checklist for facility inventory Client-provider interaction observation Health-care provider interview tool Support staff interview tool Adult client exit interview tool Coverage measurement tools Adult community member interview tool Adolescent in the community interview tool v vi 1 7 8 22 30 41 46 58 63 69 70 74

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS iii ©SHREYA NATU

©AUSAID

ACKNOWLEDGMENTS The World Health Organization (WHO) is grateful to UNAIDS and all those who gave technical input into the production of this document. Lead writers: Subidita Chatterjee (independent consultant) and Valentina Baltag (WHO). WHO working group: Paul Bloem, Krishna Bose (formerly WHO), Venkatraman Chandra-Mouli, Charlotte Christiansen (formerly WHO), Jane Ferguson, Nuhu Yaqub.  Peer review (WHO): Anastasyia Dumcheva, (WHO Country Office in Ukraine), Symplice Mbola Mbassi (WHO Regional Office for Africa), Howard Sobel (WHO Regional Office for the Western Pacific). Peer review (UNAIDS): staff members. Peer review (external review group): Regina Benevides (Evidence to Action, United States of America), Doortje Braeken (International Planned Parenthood Federation, United Kingdom), Scott Burnett (loveLife, South Africa), Danielle Engel (United National Population Fund, United States of America), Mychelle Farmer (Jhpiego, United States of America), Bamikale Feyisetan (Evidence to Action, United States of America), Gwyn Hainsworth (Pathfinder International, United States of America), Jari Kempers (Qalys Health Economics, Estonia), Vijay Kumar (Survival for Women and Children Foundation, India), Catherine Lane (United States Agency for International Development, United States of Amercia), Laura Laski (United National Population Fund, United States of America), Galina Lesco (National Resource Centre in YFHS “Neovita”, Republic of Moldova), Ricky Lu (Jhpiego, United States of America), Elizabeth Mapella (Ministry of Health, United Republic of Tanzania), Edgar Necochea (Jhpiego, United States of America), Beth Outterson (Save the Children, United States of America), Elizabeth Saewyc (University of British Columbia, Canada), Olena Sakovych (United Nations Children’s Fund, Ukraine), Susan Sawyer (University of Melbourne, Australia), Kat Watson (International Planned Parenthood Federation, United Kingdom), Sylvia Wong (United National Population Fund, United States of America). Editing: Jura Editorial Services, Gex, France.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS v

ABBREVIATIONS HMIS NGO SOP WHO health management information systems nongovernmental organizations standard operating procedure World Health Organization

vi GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS ©GRAHAM CROUCH/WORLD BANK

INTRODUCTION This document is part of the Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health-care services for adolescents. It is one of four volumes published separately, which include: • Volume 1: Standards and criteria • Volume 2: Implementation guide • Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards • Volume 4: Scoring sheets for data analysis This volume, Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards, includes tools to determine whether the implementation of the standards has been achieved. These tools can be adapted for use in different contexts – be it selfassessments on a limited number of criteria, or external assessments (monitoring visits) by district managers, on a wider, or full range, of standards and criteria. The tools can be equally adapted to develop checklists for supportive supervision. The toolkit included in this volume contains seven tools to collect data about quality of care (as measured by the criteria of the standards) and two tools to gather information about coverage. The questions/items included in the tools are selected because they provide information about the criteria of the standards and whether or not facility-level actions in the implementation guide are taking place. Each of the criterion of the global standards can be measured in several ways. For example, one of the output criterion of Standard 4 states: Adolescents receive services in a friendly, supportive, respectful, non-discriminatory and nonjudgemental manner. Whether or not this happens can be identified by directly asking the adolescent client, by asking the health-care provider, by directly observing a provider-client interaction with an adolescent, or by a combination of above. Although collecting data from adolescent clients is obviously a key source of information about the quality of care provided to them, it is important to realize that adolescents will not always be aware of all that is required to provide them with quality health services. In addition, the views of adolescent clients represent one type of perspective of how the services are delivered. For these reasons, it is important to use more sources of data collection. The proposed data collection tools enable quality assessment based on various perspectives (client, provider, support staff, manager, adult client, and the assessor in the case of direct observation) (see Table A2.1).

Coverage measurement surveys Measuring the quality of services provided by the facility through exit interviews will not provide information on which proportion of the target population have access to, and use, services. If only gathering data through quality measurement surveys in the facilities, there is a risk that efforts will be limited to improving the quality of care for only a limited number of users, while a big proportion of community members may not report about their access to or use of services. From the public health perspective, a population-level impact can only be achieved if a sufficient proportion of the target population is using services that have a sufficient level of quality. This information can only be gathered by surveys in the community. The proposed tools, therefore, include interview tools for adult and adolescent community members. In addition, community surveys provide essential information regarding the implementation of Standard 1: The health facility implements systems to ensure that adolescents are knowledgeable about their own health, and they know where and when to obtain health services, and Standard 2: The health facility implements systems to ensure that parents, guardians and other community members and community organizations recognize the value of providing health services to adolescents and support such provision and the utilization of services by adolescents. These two standards cannot be measured by facility-based surveys alone. Table 1 provides an overview of the various questions in the data collection tools that relate to each of the standards and their criteria.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 1

Table 1. Mapping of questions in data collection tools that relate to each of the standards and their criteria1 Criterion number Standard 1 1 2 3 4 5 6 7 8 2 11a-b 8, 17a-b 25a-b, 26a-b, 27a, 28a, 28c-d, 29a-b, 30a-b, 32, 33a-b 9, 10, 27b, 28b, 28e, 29c, 30c, 31, 33c 5 3a 16b 1a-c 2b 13a 13h 9e 16b-c 4a, 25 15a 34 20 35c-e 6a 9 11a-b 26a-b 30 31a-b, 32, 33a-b, 34a, 34c-d, 35a-b, 36a-b, 38, 39a-b 27, 33c, 34b, 34e, 35c, 36c, 37, 39c 5b AE FM OT CPI HCP SS Adult E Adult C AC

9

-

-

-

-

-

-

-

10 11 12 13 14 15 16 17 18 19 20

3b 18a 16a 18d 7b, 16c 7c-d, 18b

13b 15a 9h 9g 9f 15d 14a 9d, 14b-c, 15b

-

4b, 19 17a 18 35a 35b 6 8a 8b-c

-

3a-c 4a-c 5a, 6a-h -

3a-b 4a-c 1b, 2a, 5a-h -

1

Criteria 33, 54 and 58 are not measured by specific questions. See the explanations for these criteria in Volume 4: Scoring sheets for data analysis.

2 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Criterion number 21 22 23 24 25 26 27 28 29 30 31 32

AE 24, 29d 22b 7 14a, 15, 16 17c-i 17j-k, 18b

FM 5, 6a-f 3d, 4a 3c, 3e, 4a 10a-d 7a 7p-q 17a-b -

OT 16a-f 13d 13c, 13e 12a-d 6l, 11a-v 9j, 14o-p -

CPI 16a 17a-b 13a-g 5a-e, 6b-c, 8, 9, 10, 16l-m -

HCP 3a-v, 17b 2 4d 4c, 4e 24 5 7a-v, 22a-g 21a-c, 21e

SS 5, 6b-d 7, 8 -

Adult E -

Adult C -

AC 29, 35d 22b 10, 22b, 29 14b, 15 16, 17a, 21b

34

14b, 17j-k, 18b 17o -

-

-

-

-

-

-

14c, 16, 17a, 21b 19 -

35 36

7g-i, 17e

2a, 2c-e, 4, 5a-b, 14f-h 3a-i 8a-d, 10b-g, 14d 9c, 15c 15c 10a-g

-

11a-c, 27

10a-d

-

-

37 38

-

15c, 17d 7e, 11a-e 15a, 18c 15b, 18c -

-

8g, 9

17

-

-

39 40 41 42

4, 12c, 17m

2, 3, 4, 6a, 7, 9, 10,15

13, 14 21d, 21g-k

13 16

7c, 8b

-

6b, 12c, 17b, 18a

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 3

Criterion number 43 44

AE 19 20

FM -

OT 6p-r, 7a-s 6a-k, 6m-o, 6s-t 14j 12d, 13f, 14i 12b 9a-b 13g 9i, 14k 14n 9k 9l 9m 9n 14l-m 14e -

CPI -

HCP 28a 28b

SS -

Adult E -

Adult C -

AC 24 25

45 46 47 48 49 50 51 52 53 55 56 57 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

12a-b 12d-e, 13a-c 4, 12c, 17l, 17n 19, 20 15 21a 17o-p

7k, 10b 7j, 10d 3f 12 3g, 4b 7l 4c, 9e 7o, 17f 9c 9d, 16d 8a-c 13 14 19b 7m-n 7f 9a-b -

11, 12 14, 16d-k, 16m

8e 8f 4f 10 23a-e 16c 29a 4g 30a 12, 30b 31a 26a-b 32a 29b 31b-c 8d 16a 21f

14, 15 11a 9 12a 11b-c -

-

-

12a-b 12d-e, 13a-c 6b, 12c, 18b 24, 25 14a 23a 19, 20a

4 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Criterion number 76 77 78 79

AE 23b 17q 23a

FM 17c -

OT 13i -

CPI -

HCP 15b 16b

SS -

Adult E -

Adult C -

AC 28b 20b 28a

AE=adolescent client exit interview tool FM=facility manager interview tool OT= Observation tool and checklist for facility inventory CPI=client-provider interaction observation HCP=health-care provider interview tool SS=support staff interview tool Adult E= adult client exit interview tool Adult C=adult in the community interview tool AC= adolescent in the community interview tool

National adaptation of tools The proposed tools are constructed to measure the global standards. If changes were made in the process of the national adaptation of the global standards, the tools will need to be adapted as well to make sure they are actually measuring the national standards. Below are some considerations in the process of adaptation of the tools.

If only minor changes were made in the process of national adaptation of the global standards (e.g. in the title of the cadre/personnel) • Use the included tools as a basis, and adjust/adapt as necessary.

If new standards, or new criteria within the standards, were added in the process of national adaptation of the global standards • Decide which data collection methods are best suited to assess the new criteria (e.g. adolescent client exit interview? observation? provider interview?). Make sure you collect data from at least two sources for each new criterion. • Translate each new criterion into questions for the respective tools, and add these new questions in the corresponding questionnaires. • Review the questionnaires for internal consistency, good flow of the questions, and to eliminate redundancies.

If standard(s), or criteria within the standards, were eliminated in the process of national adaptation of the global standards • Identify the questions in the tools that correspond to the eliminated standards or criteria. • Review the changed questionnaires for internal consistency and good flow of the questions.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 5

Summarizing data in aggregate scores An efficient way to summarize all the data that has been collected is to calculate an overall score for each standard that was assessed. Scoring is based on a point system in which low points, “0”, are assigned to answers/items indicating lower quality performance and high points, “1”, are assigned to answers/items indicating stronger or higher quality performance. To moderate the relative value of the observation vis-a-vis other data sources, in three instances a “weighted” score was applied (see Box 1). A score per standard is presented as a percentage of the maximum possible score, and is calculated by quantifying the information collected on the standard from each data source then averaging all of the scores from each data source (see Volume 4: Scoring sheets for data analysis). Countries may set thresholds to judge the level of implementation of standards, for example: Score 10% or less Score 10%–40% Score 40%–80% Not meeting standards Needs major improvement Needs some improvement

Score 80% or more Meets standards

Box 1. Weighting the relative importance of observation vis-a-vis other verification means Depending on the criterion, the importance of direct observation vis-a-vis other verification means may vary. For example, the best way to measure Criterion 27, “Providers’ obligations and adolescents’ rights are clearly displayed in the health facility,” is to observe if the rights are clearly displayed. However, if the usual score of “1” is applied for an observed display of rights, then the results would be dominated by the other data sources used to measure this criterion. Therefore, a multiplier ×2 is applied to give more weight to the observation as a measurement method. Conversely, Criterion 43, “Medicines and supplies are in adequate quantities without shortages (stock-outs), and are equitably used” and Criterion 44, “The equipment necessary to provide the required package of services to adolescents is available, functioning and equitably used” would usually be given a usual score of “1” if medicines or equipment are present. If measured this way, the results would be dominated by the observation (availability of the medicine or equipment) and would leave little space to detect inequitable use, which is measured by the other data sources. Therefore, a multiplier of ×0.75 is applied to reflect in a more balanced manner both the “availability” and “equitable use” of medicines and equipment in the final score. In the majority of cases, the score from the direct observation constitutes approximately 50% of the total score. While in general this may be adequate, countries may decide during the process of adaptation if, and which, criterion should have weighted scores applied.

6 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

QUALITY MEASUREMENT TOOLS

©MARCO DORMINO/UN PHOTO

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 7

ADOLESCENT CLIENT EXIT INTERVIEW TOOL FACE SHEET Participant Code ____ ____ ____ ____ NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS1 OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 4 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

1

The subnational political-administrative units in countries vary, and adaptations should be made as to the relevance of address items such as state/region/province/district/zone.

8 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

INTRODUCTION AND CONSENT Consent form for parent(s)/guardian(s) accompanying adolescents less than 18 years of age

Hello, My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I am interested in your son’s/daughter’s/ward’s opinions, and I would like to talk to him/her about his/her experience using this health facility. For this I would like to ask him/her a few questions. This information will help to improve health services for adolescents. This interview will take about 20–25 minutes. I will not write down his/her name, and all the information he/she provides will be kept strictly confidential and not be shared with anyone else. His/her participation in this survey totally depends on you and him/her. If you wish you may refuse to give us permission to interview your son/daughter/ward. If you decide your son/daughter/ward should not participate, it will not affect his/her access to services at this health facility in any way. Do you have any questions? May we begin? The parent/guardian has given permission Yes......... 1 No.......... 2 “All my questions were answered. I have understood and agree to give consent to the interview.” Signature/thumb impression/verbal consent of the parent/guardian: _________________________________________________________________________________________________ _________________________________________________________________________________________________ DATE: ____ ____

D D

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

Signature of Interviewer: _____________________________________________________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 9

Consent form for the adolescent client

My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I am interested in your opinions, and I would like to talk to you about your experience of using this health facility. For this I would like to ask you a few questions. This information will help to improve health services for adolescents. This interview will take about 15 to 20 minutes. I will not write down your name and all the information you provide will be kept strictly confidential and not be shared with anyone else. Your participation in this survey totally depends on you (and your parent/guardian, if relevant). If you wish you may refuse to participate. If you choose not to participate, it will not affect your access to services at this health facility in any way. If you do choose to be interviewed, you do not have to answer every question I ask you. Do you have any questions? May we begin? The interviewee has agreed to answer Yes......... 1

No.......... 2 “All my questions were answered. I have understood and agree to give consent to the interview.” Signature/thumb impression/verbal consent of the adolescent client: _________________________________________________________________________________________________ _________________________________________________________________________________________________ DATE: ____ ____

D D

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

Signature of Interviewer: _____________________________________________________________

10 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

ADOLESCENT CLIENT EXIT INTERVIEW TOOL Question number 1 2 Criterion number 1 Questions for the adolescent client exit interview Is this your first visit to this facility? Did you notice any signboard in a language you understand that mentions the operating hours of the facility? Today, if someone accompanied you, could you tell me who it was? Response & Code First............................... 2 Repeat.......................... 3 Yes ............................... 1 No................................. 0 I came alone.................. A Parent/guardian............. B Sibling........................... C Spouse.......................... D Friend............................ E Other (please specify).....F ______________________ 4 42, 47 If you came accompanied by another person, did you have some time alone with the health-care provider? Does your guardian (parent/spouse/ in-laws/other) support your using this health facility? Today, what services did you come to this facility for? Today, did you get the services that you came for? Did anybody tell you, today or in other occasions, what other services you can obtain in this facility? Could you tell me what (other) services are provided to adolescents in this facility? (Probe to see if he/she can mention some services.) Yes ............................... 1 No................................. 0 Yes ............................... 1 No ................................ 0 Don’t know ................... 8 ______________________ Yes ............................... 1 No................................. 0 Yes ............................... 1 No ................................ 0 Yes................................ 1 No................................. 0 Physical and pubertal development................. A Menstrual hygiene/ problems....................... B Nutrition......................... C Anaemia........................ D Immunization ................ E STIs................................F HIV................................G è Skip to Q 10 Code “yes” if at least 2 other services are named apart from the service he/she came for. è Skip to Q5 Remarks

3

-

5

17

6 7

23

8

6

9

9

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 11

Question number

Criterion number

Questions for the adolescent client exit interview

Response & Code Oral contraceptive pills................................ H Condoms........................I IUD.................................J Emergency contraceptive pills................................ K Implants.........................L Injectables.................... M Antenatal care............... N Safe delivery..................O Postpartum care............ P Safe abortion.................Q Post-abortion care......... R Dermatological.............. S Mental health................. T Substance use.............. U Violence........................ V Injuries.......................... W Fever............................. X Diarrhoea....................... Y Malaria.......................... Z Tuberculosis................ ZZ Other (please specify).ZZZ ______________________

Remarks

10

9

If one day you will need services that are not provided in this facility, do you know where to go, or whom to ask? Did you see informational materials for adolescents, including video or TV, in the waiting area? Did you like the informational materials?

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No................................. 0 Don’t know.................... 8 è Skip to Q 12

11

a)

2

b)

2

12 a) b) 45 45

Today, when you visited the facility, did you find that it has: Working hours that are convenient for you? A reasonably short waiting time? (ask how long the client waited) Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Code “yes” if the waiting time was 30 minutes or less.

c)

42, 47

Curtains in doors and on windows so that nobody can see you during the examination? Comfortable seating in the waiting area?

Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

d)

46

12 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number e) 13 a) b) c)

Criterion number 46

Questions for the adolescent client exit interview Drinking water available?

Response & Code Yes ............................... 1 No................................. 0

Remarks

Were the following sufficiently clean: 46 46 46 Surroundings? Consultation areas? Toilets, which were functional? Have you seen a display with your rights? Can you tell me what your rights are? Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Considerate, respectful and non-judgemental attitude…...................... A Respect for privacy during consultations, examinations and treatments..................... B Protection from physical and verbal assault.......... C Confidentiality of information.................... D Non-discrimination........ E Participation...................F Adequate and clear information ………..G Code “yes” if at least 3 mentioned from the list provided.

14

a) b)

27 34

15

27, 52

Have you seen a display which mentions that services will be provided to all adolescents without discrimination? Have you seen a display of the confidentiality policy?

Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

16 17 a)

27

Today, during your consultation or counselling session: 6 Did any service provider talk to you about how to prevent diseases and what to do to stay healthy? Did the service provider inform you about the services available? Did the service provider ask you questions about your home and your relationships with adults? Did the service provider ask you questions about school? Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

b) c)

6 31

d)

31

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 13

Question number e) f)

Criterion number 31 31

Questions for the adolescent client exit interview Did the service provider ask you questions about your eating habits? Did the service provider ask you questions about sports or other physical activity? Did the service provider ask you questions about sexual relationships? (Ask this question only to adolescents of an appropriate age.1)

Response & Code Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

Remarks

g)

31

h)

31

Did the service provider ask you questions about smoking, alcohol or other substances? Did the service provider ask you questions about how happy you feel, or other questions about your mood or mental health? Did the service provider treat you in a friendly manner? Was the service provider respectful of your needs? Did anyone else enter the room during your consultation? Did the service provider assure you at the beginning of the consultation that your information will not be shared with anyone without your consent? Do you feel confident that the information you shared with service provider today will not be disclosed to anyone else without your consent? Do you feel that the health information provided during the consultation was clear and that you understood it well? Did the provider ask you if you agree with the treatment/procedure/ solution that was proposed? Overall, did you feel that you were involved in the decisions regarding your care? For example, you had a chance to express your opinion or preference for the care provided, and your opinion was listened to, and heard? Today, did you have any contact with anyone from support staff (receptionist, cleaning staff, or security staff)?

Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

i)

31

j) k) . l) m)

32, 34 32, 34 47 42

n)

47

Yes ............................... 1 No................................. 0

o)

35, 75

Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Don’t know.................... 8

p)

75

q)

78

18

a)

Yes................................ 1 No................................. 0 è Skip to Q 19

14 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number b)

Criterion number 32, 34

Questions for the adolescent client exit interview Did you feel that support staff were friendly and treated you with respect? Today, did you not get the services you wanted because of a lack of medicines or other materials? Today, did you not get the services you wanted because of a lack of equipment, or because the equipment was not functioning? Today, were you denied necessary services at this health facility? If yes, what do you think was the reason for the denial?

Response & Code Yes ............................... 1 No................................. 0 Yes ............................... 0 No................................. 1 Yes ............................... 0 No................................. 1 Yes................................ 0 No................................. 1 Age below 18................ A Unmarried..................... B Not in school................. C Inability to pay............... D Unavailable in the facility............................ E The condition needs referral............................F Other (please specify)....G ______________________

Remarks

19

43, 48

20

44, 48

21

a)

57

è Skip to Q 22

b)

57

c)

57

Which services were denied?

Nutritional...................... B Anaemia........................ C Immunization................. D Menstrual hygiene / problems....................... E RTI and STI....................F HIV................................G Oral contraceptive pills.. H Condom..........................I IUD.................................J Emergency contraceptive pills................................ K Implants........................ K Injectables .................... K Medical abortion/ menstrual regulation/ surgical abortion............ L Post-abortion care........ M Antenatal care...............O Postnatal care...............Q Dermatological.............. R Mental health................. S Substance use.............. T Sexual violence.............. U Other (please specify).... V ______________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 15

Question number 22 a)

Criterion number -

Questions for the adolescent client exit interview Today, has any service provider referred you to another health facility for services not provided here? Did the provider give you a detailed referral note (stating the health condition, address of the referral, working hours and cost of services)? Today, or in other occasions, were you or your friends approached to help staff in working with adolescents in this adolescent clinic/ health facility? Today, or in other occasions, were you or your friends approached to help facility staff in planning health services, or any activity to improve the quality of services such as surveys, participating in meetings to discuss the quality of care, or any other? Have you ever received information, counselling or health services in the community setting (for example in school, clubs, community meetings, or any other?) What do you know about anaemia?

Response & Code Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

Remarks

è Skip to Q 23

b)

22

23

a)

79

b)

77

Yes ............................... 1 No................................. 0

24

21

Yes ............................... 1 No................................. 0

25

a)

8

Nothing......................... 0 Satisfactory answer (yes)............................... 1 Less haemoglobin/ blood............................. A It leads to: Weakness/tiredness...... B Loss of appetite............. C Repeated illness............ D Slow growth and stunting......................... E Other (please specify).....F ______________________

Code “yes” if at least 2 items from the list were named.

b)

8

Do you know how to prevent anaemia?

Yes ............................... 1 No................................. 0 Iron and folic acid tablets........................... A Eat leafy greens ............ B Eat vegetables............... C Eat meat and liver.......... D Drink milk...................... E Eat eggs.........................F Have a balanced diet.....G Other (please specify).... H ______________________

Code “yes” if at least 2 items from the list were named.

16 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 26 a)

Criterion number 8

Questions for the adolescent client exit interview Can you name any health or other consequences of getting married very young?

Response & Code Yes ............................... 1 No................................. 0 Dropping out of school .A Early childbirth............... B More prone to sexually transmitted diseases...... C Other (please specify).... D ______________________

Remarks Code “yes” if at least 2 items from the list were named.

b)

8

Can you name any health consequences of having a baby at a young age?

Yes ............................... 1 No................................. 0 Anaemia........................ A Babies with low birth weight .......................... B Death of the mother....... C Difficult labour................ D Preterm birth................. E Death of the baby...........F Other (please specify)....G ______________________

Code “yes” if at least 2 items from the list were named.

27

a)

8

Do you know what is the minimum number of check-ups that a pregnant woman should get? (Ask 15–19 year olds only.)

Correct answer.............. 1 Doesn’t know or incorrect answer............ 0

Check the country policy for the recommended minimum number of check-ups.2 Code “correct answer” if at least 1 type of facility in line with national policy was named.3

b)

9

Do you know where an adolescent girl can go for such check-ups? (Ask 15–19 year olds only.)

Correct answer.............. 1 Doesn’t know or incorrect answer............ 0 Possible answers: Government hospital..... A Adolescent clinic............ B Health centre/office........ C Auxiliary nurse midwife office............................. D Private hospital.............. E Other (please specify).....F ______________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 17

Question number 28 a)

Criterion number 8

Questions for the adolescent client exit interview Can you name any methods of contraception? (Ask 15–19 year olds only.)

Response & Code No................................. 0 Yes ............................... 1 Condom........................ A Oral contraceptive pills... B Emergency contraceptive pills.......... C IUD................................ D Injectables..................... E Implants........................ E Abstinence.....................F LAM..............................G Standard Days Method... H Withdrawal......................I Others (please specify)....J ______________________

Remarks è Skip to Q 29 Code “yes” if at least 3 methods from the list, with at least 2 modern contraceptives, were named.

b)

9

Do you think you could get one if you needed it? (Ask 15–19 year olds only.)

Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 è Skip to Q 29

c)

8

Have you heard about emergency contraceptive pills? (Ask 15–19 year olds only.)

d)

8

Do you know what they are used for? (Ask 15–19 year olds only.) (Probe for how they are used.)

Yes ............................... 1 No................................. 0 Stopping a pregnancy from happening............. 1 Other (please specify).. 10 ______________________ Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0 For contraception/ preventing pregnancy.... A Preventing HIV or other sexually transmitted infections....................... B Other (please specify).... C ______________________ è Skip to Q 30 Code “yes” if both pregnancy and STI prevention is mentioned.

e)

9

Do you think you could get them if you needed them? (Ask 15–19 year olds only.)

29

a)

8

Have you heard about condoms? (Ask 15–19 year olds only.)

b)

8

Could you tell me why a condom is used? (Ask 15–19 year olds only.)

18 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number c)

Criterion number 9

Questions for the adolescent client exit interview If you or your friends would need a condom, can you tell me where to get one? (Ask 15–19 year olds only.)

Response & Code Yes ............................... 1 No................................. 0 Shop............................. A Pharmacy...................... B Government hospital/ clinic/family planning centre............................ C Adolescent clinic............ D Private hospital/clinic/ family planning centre.... E Community volunteer......F Auxiliary nurse midwife..G Other (please specify).... H ______________________

Remarks Code “yes” if at least one place is mentioned.

d)

21

Do you feel you could get a condom if you needed one? (Ask 15–19 year olds only.) Have you heard of HIV?

Yes ............................... 1 No................................. 0 Don’t know.................... 8 Yes ............................... 1 No................................. 0 è Skip to Q 31 Code “yes” if all five questions are answered correctly.

30

a)

8

b)

8

Could you please answer the following questions on HIV?

Yes ............................... 1 No................................. 0 Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners?....................... A Can a person reduce the risk of getting HIV by using a condom every time they have sex?....... B Can a healthy-looking person have HIV?.......... C Can a person get HIV from mosquito bites?..... D Can a person get HIV by sharing food with someone who is infected?....................... E

c) 31

9 9

If you would want to get tested for HIV would you be able to get tested? If an adolescent in your locality had an unwanted pregnancy, would they know where to go for medical advice?

Yes ............................... 1 No................................. 0 Yes ............................... 1 No................................. 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 19

Question number 32

Criterion number 8

Questions for the adolescent client exit interview Do you know what care to take each month during the menstrual cycle? (Ask girls only.)

Response & Code Yes ............................... 1 No................................. 0 Daily shower.................. A Use soft and clean cloth.............................. B Wash cloth with soap and water...................... C Dry cloth in sunlight....... D Store cloth in clean place............................. E Use sanitary napkins ......F How to dispose of sanitary napkins.............G Other (please specify).... H ______________________

Remarks

33

a)

8

Have you ever heard of diseases that can be transmitted through sexual intercourse? (Ask 15–19 year olds only.)

Yes ............................... 1 No................................. 0 Don’t know.................... 8 Yes ............................... 1 No................................. 0 Abdominal pain (only in women)............. A Genital discharge........... B Foul smelling discharge.C Burning pain on urination........................ D Genital ulcers/sores....... E Swelling in the groin area................................F Other (please specify)....G ______________________ Skip to Q 34

b)

8

Do you know any symptoms of sexually transmitted infections? (Ask 15–19 year olds only.)

c)

9

If you or someone of your age had these problems, would you know where to go for check-up and treatment?

Yes ............................... 1 No................................. 0 Self-treat........................ A Traditional healer............ B Adolescent clinic............ C Government facility........ D Auxiliary nurse midwife... E Private clinic...................F Other (please specify)....G ______________________

34

a)

-

Do you have any ideas for how adolescents could get more involved in planning, designing and implementing good quality health care in this community?

Yes................................ 1 No................................. 0 è End the interview with thanks.

20 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number b)

Criterion number -

Questions for the adolescent client exit interview Can you please share your ideas with us?

Response & Code ______________________ ______________________ ______________________ ______________________

Remarks

End the interview with thanks. Notes for adaptation: 1

The appropriate age will be decided during the national adaptation, and it should be based on local statistics regarding the age of sexual initiation. Adapt according to the country policies; the WHO-recommended minimum number of antenatal visits is four. Adapt list according to the country policies.

2 3

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 21

HEALTH FACILITY MANAGER INTERVIEW TOOL FACE SHEET Interviewee Code ____ ____ ____ ____ NAME OF THE PERSON: _________________________________________________ SEX: Male……1 Female……2

NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 3 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

22 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

INTRODUCTION AND CONSENT Consent form for the health facility manager

Hello, My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I would like to ask you and your staff some questions. Then, I would like to observe the environment for service provision at your health facility and access some of your records. In addition, I would like to inquire about the medicines and supplies available. At the end I would like to be present during at least one adolescent client-provider interaction. All this information will help to improve the quality of health care for adolescents in (the district, country) ______________________________. Observing the environment for service provision at the health facility will require about 35–40 minutes. Conducting the interviews will require about 60 minutes. All the information that you and your staff provide in the interview will be kept confidential and will not be shared with anyone else. This survey is anonymous and the questionnaire will not be seen by anyone not involved in the survey analysis. Your participation in this review process is voluntary. You may decide not to participate in this interview or not to answer some of the questions.

Do you have any questions? May we begin?

Interviewee has agreed to participate

Yes......... 1

No.......... 2 Permission for observation is available Yes......... 1

No.......... 2

Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 23

HEALTH FACILITY MANAGER INTERVIEW TOOL Question number 1 Criterion Questions for the health facility number manager For how long have you been working in this position? Could you tell me how many staff you have: AND How many of them are trained in the provision of health-care services to adolescents specifically? a) Available Response & Code Remarks

____ ____ Years

/ ____ ____ Months

2

-

b) Trained in the provision of health-care services to adolescents specifically ____ ____ ____ ____ ____ ____ Doctor Nurse Midwife ____ ____ ____ ____ ____ ____

Doctor Nurse Midwife

Counsellor ____ ____ Outreach worker ____ ____

Counsellor ____ ____ Outreach worker ____ ____

Support staff (specify) ____ ____ __________________ 3 a) 3

Support staff (specify) ____ ____ ______________________

Could you tell me which of these components were covered by the training in adolescent health? Communication skills to talk to adolescents Yes ............................... 1 No ................................ 0 Don’t know ................... 8 b) 10 Communication skills to talk to adult visitors/community members Yes ............................... 1 No ................................ 0 Don’t know ................... 8 c) 26 The policy on privacy and confidentiality Yes ............................... 1 No ................................ 0 Don’t know ................... 8 d) 25 Clinical case management Yes ............................... 1 No ................................ 0 Don’t know ................... 8 e) 26 Orientation on the importance of respecting the rights of adolescents to information and health care that is provided in a respectful, non-judgemental and non-discriminatory manner Policies and procedures to ensure free or affordable service provision Yes ............................... 1 No ................................ 0 Don’t know ................... 8 Yes ............................... 1 No ................................ 0 Don’t know ................... 8 g) 60 Data collection, analysis and use for quality improvement Yes ............................... 1 No ................................ 0 Don’t know ................... 8

f)

51

24 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 4 a) b) c) 5

Criterion Questions for the health facility number manager Did you undergo any of the following trainings as facility manager? 25, 26 60 62 24 Orientation in adolescent health care Training in quality improvement for adolescent health care Training in supportive supervision for adolescent health care Do you have job descriptions for each category of staff employed in your facility?

Response & Code

Remarks

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Don’t know ................... 8 Skip to Q7

6 a) 24

Do the job descriptions of your staff include a focus on adolescent health care? Doctor Yes ............................... 1 No ................................ 0 Don’t know ................... 8 b) 24 Nurse Yes ............................... 1 No ................................ 0 Don’t know ................... 8 c) 24 Midwife Yes ............................... 1 No ................................ 0 Don’t know ................... 8 d) 24 Outreach worker Yes ............................... 1 No ................................ 0 Don’t know ................... 8 e) 24 Counsellor Yes ............................... 1 No ................................ 0 Don’t know ................... 8 f) 24 Other (please specify) _____________________________________ Yes ............................... 1 No ................................ 0 Don’t know ................... 8

7 a) b) 28 19

Do you have any of the following guidelines/SOPs in your facility? Clinical case management guidelines or job aids/algorithms for adolescent health care SOPs for which services should be provided in the facility and which in the community Referral guidelines Policy/SOPs for a planned transition from paediatric to adult care Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 d) 20 Yes ............................... 1 No ................................ 0

c)

20

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 25

Question number e) f) g)

Criterion Questions for the health facility number manager 38 73 36 Guidelines/SOPs on protecting the privacy and confidentiality of adolescents Guidelines/SOPs on informed consent Guidelines/SOPs with staff responsibilities on making the health facility welcoming, convenient and clean SOPs on how to minimize the waiting time for adolescent clients SOPs on how to provide services to adolescents with, or without, an appointment Guidelines/SOPs on how to provide free, or affordable, services to adolescents Guidelines/SOPs on how to provide equitable services to all adolescents irrespective of their ability to pay, age, sex, marital status and other characteristics Guidelines/SOPs on self-monitoring of the quality of care provided to adolescents SOPs on how to involve adolescents in the planning, monitoring and evaluation of health services and service provision SOPs on how to involve vulnerable groups of adolescents in the planning, monitoring and evaluation of health services and service provision Guidelines/SOPs on how to reward and recognize highly performing staff Guidelines/SOPs on supportive supervision in adolescent health care Tools for supportive supervision in adolescent health care

Response & Code Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

Remarks

h) i)

36 36

j) k)

50 49

l) m)

61 72

n)

72

o) p) q) 8 a)

63 29 29

Do you regularly conduct supportive supervision visits with a focus on adolescent health care: 66 To facility health-care providers? Yes ............................... 1 No ................................ 0 b) c) 66 66 To support staff? To outreach workers? Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

9 a) 74

Does your facility regularly conduct self-assessments: To identify adolescents’ expectations about the services in the facility? Yes ............................... 1 No ................................ 0

26 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number b) c) d) e) 10 a)

Criterion Questions for the health facility number manager 74 64 65 62 To find out about adolescents’ experience of care? To assess the quality of health-care services? To establish action plans for improvements? To inform priorities for supportive supervision?

Response & Code Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

Remarks

Do you have the following information items displayed in the facility? 27 The rights of adolescents to information, non-judgemental attitude and respectful care The policy commitment of the health facility to provide health services to all adolescents without discrimination and to take remedial actions, if necessary The policy on confidentiality and privacy The policy on free or affordable service provision for adolescents Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 d) 27, 50 Yes ............................... 1 No ................................ 0

b)

27, 49

c)

27

11 a) 38

In your facility, are the following procedures established to ensure privacy, confidentiality and the security of medical information? Information on the identity of the adolescent and the presenting issue are gathered in confidence during the registration. Staff do not disclose any information given to or received from an adolescent to third parties, such as family members, school teachers or employers, without the adolescent’s consent. Case records are kept in a secure place, accessible only to authorized personnel. Measures are implemented to prevent unauthorized access to electronically stored information. To maintain privacy during the consultation, there are curtains in windows and doors and a screen separating the consultation area from the examination area. Is there a system in place in the facility to collect data on cause-specific service utilization by adolescents that is disaggregated by age and sex? Do facility reports to the district include data on cause-specific service utilization by adolescents that is disaggregated by age and sex? Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

b)

38

c) d)

38 38

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

e)

38

12

59

13

68

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 27

Question number 14 15 a)

Criterion Questions for the health facility number manager 69 Do facility reports to the district on quality of care have a focus on adolescents? Do you ensure that there are systems in place for: 39 Procurement and stock management of the medicines and supplies necessary to deliver the required package of services to adolescents? Procurement, inventory, maintenance and safe use of the equipment necessary to deliver the required package of services to adolescents? Basic amenities (electricity, water, sanitation and waste disposal)? Does the facility have a documented plan:

Response & Code Yes ............................... 1 No ................................ 0

Remarks

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

b)

40

c) 16 a)

37

12

To inform adults, when they visit the health facility, during community meetings and through community organizations, about the value of providing services to adolescents? To inform adolescents in the community (in schools, clubs, community meetings) about their health and the services available? For provision of health services to adolescents in community settings? For actions to improve the quality of care in the facility based on the results of the last self-assessment? Do you have budget to ensure:

Yes ............................... 1 No ................................ 0

b)

5

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

c) d)

19 65

17 a) 30

Continuous professional education activities in adolescent health care for facility staff? Training of outreach workers in adolescent health care? Training of adolescents in providing certain services (e.g. health education for peers, counselling)? Maintaining basic amenities of the facility in good condition? Keeping the facility welcoming and clean? Rewarding highly performing staff?

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0

b) c)

30 76

d) e) f)

37 36 63

28 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 18 a)

Criterion Questions for the health facility number manager Do you have at hand updated lists of: 11 Agencies and organizations the facility partners with to increase community support for adolescent use of services? Organizations from the health and other sectors, for example, social, recreational, legal sectors, that provide services to adolescents in the catchment area? Medicine, supplies and necessary equipment?

Response & Code

Remarks

Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Yes ............................... 1 No ................................ 0 Don’t know ................... 8 End the interview with thanks.

b)

20

c)

39, 40

d)

18

Services included in the package of information, counselling, treatment and care services that are to be provided to adolescents? Does your facility have a governance structure/board that includes members of the community to advise you on how to plan services and make them better? Does this structure/board include adolescents?

19

a)

-

b)

71

Yes ............................... 1 No ................................ 0 Don’t know ................... 8

End the interview with thanks.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 29

OBSERVATION TOOL AND CHECKLIST FOR FACILITY INVENTORY FACE SHEET NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF OBSERVATION:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF OBSERVATION: Completed.................. 1 Partially completed...... 2 Refused...................... 4 OBSERVATION BY: _______________________________________________________________________________ TIME OBSERVATION BEGAN: ____ ____

:

____ ____

TIME OBSERVATION ENDED: ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Observer: Please check the Health facility manager consent form. Have you gotten permission for the observation, and for filling in the checklist?

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

30 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

OBSERVATION TOOL AND CHECKLIST FOR FACILITY INVENTORY Interviewer: Please observe the issues mentioned below and circle the respective code. Question number 1 a) Criterion number 1 Quality assessment questions Is there a signboard that mentions the facility operating hours? Is it clearly visible? Does it mention hours for adolescent health clinics? Does the waiting area: a) b) 36 2 Have adequate and comfortable seating? Have information, education and communication materials specifically developed for adolescents? Have drinking water? Seem welcoming overall? Seem clean overall? Check for basic amenities. a) b) c) d) e) f) g) 37 37 37 37 37 37 37 Is there a functional toilet? Does the toilet have functioning hand hygiene facilities? Is the toilet clean? Does the toilet have a disposal bin? Does the facility have permanent electricity during working hours? Does the facility have general waste disposal? Does the facility have safe storage and disposal of clinical waste and potentially infectious waste that requires special disposal – such as disposable of equipment that may have come in contact with body fluids? Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 d) e) 3 36 36 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Observation & Code Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 c) 2 1 Yes ........................ 1 No ......................... 0 è Skip to Q 2 Skip

b)

1

c)

36

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 31

Question number h) i)

Criterion number 37 37

Quality assessment questions Does the facility have safe storage and disposal of sharps? Does the facility have adequate hand hygiene facilities that are located in or adjacent to the office/examination room? Are the surroundings of the facility clean? Does the facility furniture seem adequate:

Observation & Code Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

Skip

4 5 a) b) 6 a) b) c) d) e) f) g) h) i) j) k) l) m) n)

36

36 36

Regarding quantity? Regarding the state of repair?

Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

Does the facility have the following equipment/material/ supplies:1 44 44 44 44 44 44 44 44 44 44 44 28 44 44 Blood pressure measurement machine Binaural adult stethoscope Monaural fetal stethoscope Pregnancy test strips Clinical thermometer Adult weighing scales Measuring tape Light source, for example a torch Refrigerator Haemoglobinometer Test strips for urine, 10 parameter BMI growth charts for adolescents Height meter Ophtalmoscope set Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

32 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number o) p) q) r) s) t) 7 a) b) c) d) e) f) g) h) i) j) k) l) m)

Criterion number 44 43 43 43 44 44

Quality assessment questions Otoscope set Latex gloves Single-use standard disposable or autodisposable syringes Soap or alcohol-based hand rub for hand hygiene Communication equipment (phone or shortwave radio) Computer with email/internet access

Observation & Code Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

Skip

Check the minimum levels of stock for the following medicines and supplies in the facility.2 43 43 43 43 43 43 43 43 43 43 43 43 43 Condoms Oral contraceptive pills Emergency contraceptive pills Injectable contraceptives Contraceptive implants Intravenous fluids Paracetamol Amoxicillin Atenolol Ceftriaxone Ciprofloxacin Cotrimoxazole suspension Diclofenac Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 33

Question number n) o) p) q) r) s) 8 a) b)

Criterion number 43 43 43 43 43 43

Quality assessment questions Glibenclamide Omeprazole Salbutamol Diazepam Magnesium sulfate Vaccines3

Observation & Code Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

Skip

Check for visual and auditory privacy features. 38 38 There are curtains on the doors and windows. Communication between reception staff and visitors is private and cannot be overheard, including from the waiting room. In the offices/examining rooms, there is a screen to separate the examination area from the consultation area. No one can see or hear an adolescent client from the outside during the consultation or counselling. Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

c)

38

d)

38

9 a) 59

Check to see the following registers, tools and records. The register on service utilization has data disaggregated by age and sex so that cause-specific service utilization by adolescent boys and girls can be extracted. The reporting forms have a format that allows the presentation of data disaggregated by age and sex. Stock of medicines and supplies register Referral register Register/records of accomplished outreach activities to inform adolescents in community settings Register/records of accomplished outreach activities to inform youth and other community organizations about the value of providing health services to adolescents Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 d) e) 20 7 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

b)

59

c)

39

f)

16

34 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number g)

Criterion number 15

Quality assessment questions Register/records of accomplished outreach activities to inform parents/guardians and teachers during school meetings about the value of providing health services to adolescents Record(s) of formal agreements/partnerships with community organizations to develop health education and behaviour-oriented communications strategies and materials, and plan service provision Tools for facility self-assessment of the quality of adolescent health care Tools for supportive supervision in adolescent health care Records/reports on accomplished selfassessments of the quality of adolescent health care Records of accomplished supportive supervision visits focused on adolescent health care Reports to the district on cause-specific service utilization by adolescents that include data disaggregated by age and sex Reports to the district on quality of care that have a focus on adolescents

Observation & Code Yes ........................ 1 No ......................... 0

Skip

h)

13

Yes ........................ 1 No ......................... 0

i) j) k)

61 29 64

Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

l)

66

m)

68

n) 10 a)

69

Check for confidentiality procedures and their application in practice. 42 Information on the identity of the adolescent and the presenting issue are gathered in confidence during registration. Adolescent clients are offered anonymous registration if they wish. The registration register has the name and code, but the service register has only the code (if anonymous registration is asked for). The information in laboratory registers (if applicable) is registered using codes. Case records are kept in a secure place, accessible only to authorized personnel. The registers are kept under lock and key outside operating hours. For electronically stored information, measures are applied to prevent unauthorized access. Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

b) c)

38, 42 38, 42

d) e) f) g)

38, 42 38, 42 38, 42 38, 42

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 35

Question number 11

Criterion number

Quality assessment questions Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas:

Observation & Code Clinical management Counselling

Skip

a)

28

Normal growth and pubertal development

Y-1 N-0

Information

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

b)

28

Pubertal delay

Y-1 N-0

c)

28

Precocious puberty

Y-1 N-0

d)

28

Mental health and mental health problems

Y-1 N-0

e)

28

Nutrition (including anaemia)

Y-1 N-0

f)

28

Physical activity

Y-1 N-0

g)

28

Adolescent-specific immunization

Y-1 N-0

h)

28

Menstrual hygiene and health

Y-1 N-0

i)

28

Family planning and contraception – oral contraceptive pills, IUDs, condoms, emergency contraceptive pills, implants, injectable contraceptives Safe abortion (where legal), and postabortion care Antenatal care and emergency preparedness, delivery and postnatal care Reproductive tract infections/sexually transmitted infections HIV

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

j)

28

k)

28

l)

28

m)

28

n)

28

Sexual violence

Y-1 N-0

o)

28

Family violence

Y-1 N-0

p)

28

Bullying and school violence

Y-1 N-0

36 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number q)

Criterion number 28

Quality assessment questions Substance use and substance use disorders

Observation & Code Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Skip

r)

28

Injuries

Y-1 N-0

s)

28

Skin problems

Y-1 N-0

t)

28

Chronic conditions and disabilities

Y-1 N-0

u)

28

Endemic diseases

Y-1 N-0

v)

28

Common conditions during adolescence (fatigue, abdominal pain, diarrhoea, headache)

Y-1 N-0

12 a) b) 27 27, 52

Check if the following information items are displayed in the facility. The rights of adolescents to information, non-judgemental attitude and respectful care The policy commitment of the health facility to provide health services to all adolescents without discrimination and to take remedial actions if necessary The policy on confidentiality and privacy The policy on free or affordable service provision for adolescents Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 d) 27, 50 Yes ........................ 1 No ......................... 0

c)

27

13 a) b) c) d) e) 3 10 26 25 26

Check to see training records/reports for the following topics. Communication skills to talk to adolescents Communication skills to talk to adult visitors and community members The policy on privacy and confidentiality Clinical case management of adolescent health conditions Orientation on the importance of respecting the rights of adolescents to information and health care that is provided in a respectful, non-judgemental and non-discriminatory manner Policies and procedures to ensure free or affordable service provision Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

f)

50

Yes ........................ 1 No ......................... 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 37

Question number g) h) i)

Criterion number 60 4 76

Quality assessment questions Data collection, analysis and use for quality improvement in adolescent health care Training of outreach workers in adolescent health care Training of adolescents in providing certain services (for example, health education for peers, counselling)

Observation & Code Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

Skip

14 a) b) c) d) e) f) 19 20 20 38 73 36

Check to see if there are the following guidelines/SOPs: SOPs for which services should be provided in the facility and which in the community Referral guidelines Policy/SOPs for a planned transition from paediatric to adult care. Guidelines/SOPs on protecting the privacy and confidentiality of adolescents Guidelines/SOPs on informed consent Guidelines/SOPs including staff responsibilities for making the health facility welcoming, convenient and clean SOPs on how to minimize waiting time SOPs on how to provide services to adolescents with or without an appointment Guidelines/SOPs on applying policies for free, or affordable, service provision to adolescents Guidelines/SOPs on equitable service provision to all adolescents irrespective of their ability to pay, age, sex, marital status or other characteristics Guidelines/SOPs for self-monitoring of the quality of care provided to adolescents SOPs on how to involve adolescents in the planning, monitoring and evaluation of health services and service provision SOPs on how to involve vulnerable groups of adolescents in the planning, monitoring and evaluation of health services and service provision Guidelines/SOPs on the reward for and recognition of highly performing staff Guidelines/SOPs on supportive supervision in adolescent health care Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 h) i) 36 50 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

g)

36

j)

49

k) l)

61 72

m)

72

n) o)

63 29

38 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number p) 15 a)

Criterion number 29

Quality assessment questions Tools for supportive supervision in adolescent health care Check the availability of the following lists.

Observation & Code Yes ........................ 1 No ......................... 0

Skip

11

Updated list of agencies and organizations with which the facility partners to increase community support for adolescent use of services Organizations from the health and other sectors (social, recreational, legal, etc.) providing services to adolescents in the catchment area Medicines, supplies and necessary equipment Services included in the package of information, counselling, treatment and care services to be provided to adolescents

Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

b)

20

c) d)

39, 40 18

16 a) b) c) d) e) f) 24 24 24 24 24 24

Check if the job description of the following personnel is available AND has a focus on adolescent health care. Doctor Nurse Midwife Outreach worker Counsellor Other (please specify) Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0 Yes ........................ 1 No ......................... 0

Notes for adaptation: 1 2

Adjust the list according to national lists. The minimum level of stock depends on several factors, such as average monthly consumption, procurement period and supplier lead time. The facility manager and the pharmacist should know what are the minimum levels for each item in their facility; otherwise, a proxy value of medicines necessary for at least 10 clients could be used. The specifc vaccines should be listed during the national adaptation of the tool, depending on the immunization schedule for adolescents, and the policies regarding the necessary stocks in primary care facilities.

3

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 39

INTRODUCTION AND CONSENT Consent form for the provider and client in a client-provider interaction

My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I have already examined the environment of the facility, and now would like to observe the consultation process with your client. All the information that I will hear during the consultation will be kept strictly confidential, and I will not share it with anyone else. I will not write down your names, and my notes will not be seen by anyone not involved in the survey analysis. This observation will assist the process of improving the quality of health services for adolescents. Your participation in this review process is voluntary. I would like to both of your permission to be present during the consultation.

Do you have any questions? May we begin?

Has the service provider given permission? Yes......... 1 No.......... 2 Has the client given permission? Yes......... 1

No.......... 2

Signature of interviewee(s)/thumb impression/verbal consent: _________________________________________________________________________________________________ _________________________________________________________________________________________________

40 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CLIENT-PROVIDER INTERACTION OBSERVATION Question number 1 Criterion number Quality assessment questions What was the reason for the consultation? Observation & Code Physical and pubertal development.......................... A Menstrual hygiene/problems... B Nutrition.................................. C Anaemia................................. D Immunization.......................... E STIs.........................................F HIV.........................................G Oral contraceptive pills........... H Condom...................................I IUD..........................................J Emergency contraceptive pills. K Contraceptive implant..............L Injectables ............................ M Antenatal care........................ N Safe delivery...........................O Postpartum care..................... P Safe abortion..........................Q Post-abortion care.................. R Dermatological....................... S Mental health.......................... T Substance use....................... U Violence................................. V Injuries................................... W Fever...................................... X Diarrhoea................................ Y Malaria................................... Z Tuberculosis......................... ZZ Other (please specify)......... ZZZ ___________________________ 2 42 Do you think that during the consultation the provider and the client could be seen from the outside? Is it possible to overhear the conversation between service provider and the client from the outside? Yes ........................................ 0 No ......................................... 1 Yes ........................................ 0 No ......................................... 1 Remarks

3

42

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 41

Question number 4

Criterion number 42

Quality assessment questions Apart from the service providers that were concerned with the consultation (doctor or/and nurse), was anyone else present in the room at the time of consultation? (This includes healthcare providers that are not concerned directly with this particular consultation.)

Observation & Code Yes ........................................ 0 No ......................................... 1

Remarks

5 a)  32

At the beginning of the consultation did the health-care provider: Seat the adolescent in the prime position that facilitated communication most easily? Introduce himself/herself first to the adolescent? Ask the adolescent what he/ she would like to be called? Ask the adolescent who he/ she has brought with him/her to the consultation? Show interest in the adolescent and spend some time getting to know him/ her before focusing on the medical problems (problemfree talk)? Was the adolescent accompanied by someone else (for example, parent/ guardian, sister)? a)  42 The provider explained to the adolescent that they routinely spend some time alone with the adolescent towards the end of the consultation. The provider asked questions first to the adolescent and then to the accompanying person(s). The provider asked the adolescent’s permission to ask the accompanying person(s) their opinions/ observations. Did anyone else enter the room during the consultation? Did the service provider listen with attention to what the client had to say? Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0

b)  c)  d) 

32 32 32

e) 

32

6

Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 è Skip to Q7

b) 

32

Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0

c) 

32

7 8

42 32

Yes ........................................ 0 No ......................................... 1 Yes ........................................ 1 No ......................................... 0

42 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 9

Criterion number 32, 42

Quality assessment questions Did the service provider assure the client that no information will be disclosed to anyone (parents/other) without their permission? Did the service provider explain to the client the conditions when the provider might need to disclose information, such as in situations required by law,1 and if that is the case the client will be informed of the intention to disclose unless doing so would place them at further risk of harm? Did the service provider deny any services to this adolescent/young client? Why did the service provider deny services?

Observation & Code Yes ........................................ 1 No ......................................... 0

Remarks

10

32, 42

Yes ........................................ 1 No ......................................... 0

11

57

Yes ........................................ 0 No ......................................... 1 Age below 18......................... A Unmarried.............................. B Not in school.......................... C Inability to pay........................ D Unavailable in the facility......... E The condition needs referral.....F The reason is not clear ..........G Other (please specify)............. H ___________________________ è Skip to Q 13

12

57

13 a)  31

During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about home and relationships with adults? Asked the adolescent questions about school? Asked the adolescent questions about his/her eating habits? Asked the adolescent questions about sports or other physical activity? Asked the adolescent questions about sexual relationships? (This question should only be asked to adolescents of an appropriate age.2) f)  31 Asked the adolescent questions about smoking, alcohol or other substances? Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0

b)  c) 

31 31

d) 

31

e) 

31

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 43

Question number g) 

Criterion number 31

Quality assessment questions Asked the adolescent questions about how happy he/she feels, or other questions about his/her mood or mental health? If an informed consent from a third party was required, was adolescent assent to the service/procedure also obtained? If the adolescent was accompanied by someone else (for example, parent/ guardian, sister) did the provider spend some time alone with the adolescent towards the end of the consultation?

Observation & Code Yes ........................................ 1 No ......................................... 0

Remarks

14

75

Yes ........................................ 1 No ......................................... 0 Not relevant............................ 6 Yes ........................................ 1 No ......................................... 0 Not relevant............................ 6

15

42

16 a)  21

During the consultation did the service provider do the following: Provide sufficient time for counselling or consultation as required for the problem? Talk about how to prevent diseases, and what to do to stay healthy? Inform the adolescent client about the services available for him/her? Provide accurate and clear information on the medical condition? Provide accurate and clear information on the management/treatment options? Ask the adolescent client what are his/her preferences for the management/ treatment options? Provide accurate and clear information on follow-up actions? Ask the adolescent client what are his/her preferences for the follow-up actions? Ask the adolescent client whether he/she has any problem understanding the treatment that is being provided? Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0

b) 

6

c) 

6

d) 

75

e) 

75

f) 

75

g) 

75

h) 

75

i) 

75

44 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number j) 

Criterion number 75

Quality assessment questions Check the adolescent client’s understanding of the information provided by asking probing questions? Use audio-visual material to explain anatomy, disease, or other, as relevant to the topic of the consultation? Ask the adolescent client’s permission before performing the examination/procedure? Explain the results of the physical examination to the client? Did the service provider refer the adolescent client to another health facility?

Observation & Code Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Yes ........................................ 1 No ......................................... 0 Not relevant............................ 6 Yes ........................................ 1 No ......................................... 0 Not relevant............................ 6 Yes ........................................ 1 No ......................................... 0 Not relevant............................ 6

Remarks

k) 

75

l) 

32

m) 

32, 75

17

a) 

22

Code “No” if a referral was necessary but not proposed. If a referral was not necessary and not proposed code “Not relevant”. End the observation with thanks.

b) 

22

When the service provider referred the adolescent client to another health facility, did he/she give a referral note mentioning the condition referred for, where to go (address), timing?

Yes ........................................ 1 No ......................................... 0

End the observation with thanks. Notes for adaptation: 1 2

During the adaptation, such situations – e.g. sexual assaults, gunshot wounds, suicidal or homicide risk – should be listed. The appropriate age will be decided during the national adaptation, and it should be based on local statistics regarding the age of sexual initiation.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 45

HEALTH-CARE PROVIDER INTERVIEW TOOL FACE SHEET Interviewee Code ____ ____ ____ ____ NAME OF THE PERSON: _________________________________________________ SEX: Male……1 Female……2

DESIGNATION: __________________________________________________________

NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 3 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

46 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

INTRODUCTION AND CONSENT Consent form for health-care provider

My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I would like to ask you some questions. This information will help to improve the quality of health care for adolescents in (the district, country) ______________________________. The interview will require about 25–30 minutes. All the information that you will provide in the interview will be kept confidential and not shared with anyone else. This survey is anonymous and the questionnaire will not be seen by anyone not involved in the survey analysis. Your participation in this review process is voluntary. You may decide not to participate in this interview or not to answer some of the questions.

Do you have any questions? May we begin?

Interviewee has agreed to participate

Yes......... 1

No.......... 2 Permission for observation is available Yes......... 1

No.......... 2

Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 47

HEALTH-CARE PROVIDER INTERVIEW TOOL Question number 1 Criterion number Questions for the health-care provider For how long have you been working at this health facility? Has the facility manager discussed your job description and your roles and responsibilities with you? Response & Code Remarks

____ ____ Years

/ ____ ____ Months

2

24

Yes ................................................ 1 No ................................................. 0

3

21

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Clinical management Information Counselling Referral

a)  b)  c)  d)  e)  f)  g)  h)  i) 

21 21 21 21 21 21 21 21 21

Normal growth and pubertal development Pubertal delay Precocious puberty Mental health and mental health problems Nutrition, including anaemia Physical activity Adolescent-specific immunization Menstrual hygiene and health Family planning and contraception – oral contraceptive pills, IUDs, condoms, emergency contraceptive pills, implants, injectable contraceptives Safe abortion (where legal), and post-abortion care Antenatal care and emergency preparedness, delivery and postnatal care Reproductive tract infections/ sexually transmitted infections

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

j)  k) 

21 21

Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0

l) 

21

48 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number m)  n)  o)  p)  q)  r)  s)  t)  u)  v) 

Criterion number 21 21 21 21 21 21 21 21 21 21

Questions for the health-care provider HIV Sexual violence Family violence Bullying and school violence Substance use and substance use disorders Injuries Skin problems Chronic conditions and disabilities Endemic diseases Common conditions during adolescence (fatigue, abdominal pain, diarrhoea, headache)

Response & Code Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Remarks

4 a)  b)  c)  3 10 26

Have you received the following training in adolescent health care: Communication skills to talk to adolescents? Communication skills to talk to adult visitors/community members? The policy on privacy and confidentiality? Clinical case management of adolescent patients? Orientation on the importance of respecting the rights of adolescents to information and health care that is provided in a respectful, nonjudgemental and non-discriminatory manner? Policies and procedures to ensure free or affordable service provision? Data collection, analysis and use for quality improvement? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

d)  e) 

25 26

f)  g) 

51 60

Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 49

Question number 5

Criterion number 30

Questions for the health-care provider Is there a system so that you can regularly (at least once every 5 years) attend continuous professional education training in adolescent health care? Are you aware of services included in the package of information, counselling, treatment and Questions for health-care care services tothe be provided to provider adolescents?

Response & Code Yes .................................................. 1 No ................................................... 0

Remarks

6 Question number 7

18 Criterion number

Yes .................................................. 1 No ................................................... 0 Response & Code Remarks

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Clinical management Counselling Information

a)  b)  c)  d)  e)  f)  g)  h)  i) 

31 31 31 31 31 31 31 31 31

Normal growth and pubertal development Pubertal delay Precocious puberty Mental health and mental health problems Nutrition (including anaemia) Physical activity Adolescent-specific immunization Menstrual hygiene and health Family planning and contraception – oral contraceptive pills, IUDs, condoms, emergency contraceptive pills, implants, injectable contraceptives Safe abortion (where legal), and post-abortion care Antenatal care and emergency preparedness, delivery and postnatal care

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

j)  k) 

31 31

Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0

Y-1 N-0 Y-1 N-0

50 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number l)  m)  n)  o)  p)  q)  r)  s)  t)  u)  v)  Question number 8 a)

Criterion number 31 31 31 31 31 31 31 31 31 31 31 Criterion number

Questions for the health-care provider Reproductive tract infections/ sexually transmitted infections HIV Sexual violence Family violence Bullying and school violence Substance use and substance use disorders Injuries Skin problems Chronic conditions and disabilities Endemic diseases Common conditions during Questions for the health-care adolescence (fatigue, abdominal provider pain, diarrhoea, headache)

Response & Code Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0 Y-1 N-0

Remarks

Y-1 Y-1 Response & Code N-0 N-0

Remarks

Are you aware of the following SOPs/guidelines: 19 SOPs for which services should be provided in the facility and which in the community? Referral guidelines/SOPs? Policy/SOPs for a planned transition from paediatric to adult care? Guidelines/SOPs on informed consent? Guidelines/SOPs on providing services to all adolescents irrespective of their ability to pay, age, sex, marital status or other characteristics? Guidelines/SOPs on providing free, or affordable, services to adolescents? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 c) d) e) 20 73 49 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

b)

20

f)

50

Yes .................................................. 1 No ................................................... 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 51

Question number g)

Criterion number 38

Questions for the health-care provider Guidelines/SOP on measures to protect the privacy and confidentiality of adolescents? Can you please name any measures to protect the privacy and confidentiality of adolescents? (Probe for measures in the list provided.)

Response & Code Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 1. Staff do not disclose any information given to or received from an adolescent to third parties, such as family members, school teachers or employers, without the adolescent’s consent. 2. Case records are kept in a secure place, accessible only to authorized personnel. 3. There are curtains in windows and doors, a screen separating the consultation area from the examination area to maintain privacy during the consultation. 4. Measures are implemented to prevent unauthorized access to electronically stored information. 5. Information on the identity of the adolescent and the presenting issue are gathered in confidence during client registration.

Remarks

9

38

Code “yes” if at least the first 3 items from the list were mentioned.

10

53

Do you know any groups of adolescents in your community(ies) that are vulnerable regarding health issues?

Yes .................................................. 1 No ................................................... 0 Don’t know....................................... 8

11 a) b) c) 12 36 36 36 64

Have you ever discussed with your manager and your colleagues, and undertaken actions in order to: Make working hours convenient for adolescents? Minimize waiting time? Provide services to adolescents with, or without an appointment? Did you ever participate in a facility self–assessment of the quality of care provided to adolescents? Do you think the working hours in this facility are convenient for adolescents? Can adolescents have a consultation without an appointment? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Don’t know....................................... 8 Yes .................................................. 1 No ................................................... 0 Don’t know....................................... 8

13

41

14

41

52 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 15 a) b)

Criterion number

Questions for the health-care provider

Response & Code

Remarks

Have you ever trained any of the following groups in these areas: 4 76 Outreach workers in adolescent health care? Adolescents in providing certain services, for example, health education for peers, counselling? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

16 a) 74

Have you ever involved any of the following groups in these activities: Adolescents in the planning, monitoring and evaluation of health services? Adolescents in any aspects of service provision? Vulnerable groups of adolescents in the planning, monitoring and evaluation of health services and service provision? Have you ever worked with: a) 13 Agencies and organizations in the community to develop health education and behaviouroriented communication strategies and materials and plan service provision? Organizations from health and other sectors (for example social, recreational, legal) to establish referral networks for adolescent clients? Do you inform adults visiting the health facility about services available for adolescents, and why it is important that adolescents use the services? Do you have support materials to communicate with parents, guardians and other community members and organizations about the value of providing health services to adolescents? Do you inform adolescents about the availability of health, social services and other services available? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

b) c)

79 56

17

b)

21

Yes .................................................. 1 No ................................................... 0

18

14

Yes .................................................. 1 No ................................................... 0

19

10

Yes .................................................. 1 No ................................................... 0

20

6

Yes .................................................. 1 No ................................................... 0

21 a)  b)  32 32

When you see an adolescent client for services or counselling do you: Introduce yourself first to the adolescent? Ask the adolescent what he/she likes to be called? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 53

Question number c) 

Criterion number 32

Questions for the health-care provider Ask the adolescent who he/she has brought with him/her to the consultation? Explain to adolescents that are accompanied that you routinely spend some time alone with the adolescent towards the end of the consultation? Ask the adolescent permission to ask the accompanying person(s) their opinions/observations? Obtain, in cases when an informed consent from a third party is required, the adolescent’s assent to the service/procedure? Ensure that no one can see or hear the adolescent client from outside during the consultation or counselling? Ensure that there is a screen between the consultation and examination area? Assure the adolescent client that no information will be disclosed to any one (parents/other) without his/her permission? Explain to the adolescent client the conditions when you might need to disclose information, such as in situations required by law,1 and if that is the case you will inform him/her of the intention to disclose unless doing so would place them at further risk of harm? Keep all records/lab test reports under lock and key or password protected if in the computer?

Response & Code Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

Remarks

d) 

42

e) 

32

Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

f) 

75

g) 

42

h) 

42

i) 

42

j) 

42

k) 

42

Yes .................................................. 1 No ................................................... 0

22 a) 31

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about home and relationships with adults? Asking the adolescent questions about school? Asking the adolescent questions about his/her eating habits? Asking the adolescent questions about sports or other physical activity? Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

b) c) d)

31 31 31

54 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number e)

Criterion number 31

Questions for the health-care provider Asking the adolescent questions about sexual relationships? (Only adolescents of an appropriate age.2)

Response & Code Yes .................................................. 1 No ................................................... 0

Remarks

f)

31

Asking the adolescent questions about smoking, alcohol or other substances? Asking the adolescent questions about how happy he/she feels, or other questions about his/her mood or mental health?

Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

g)

31

23 a) 55

Would you provide the following services to all adolescents regardless of sex, age, marital status or ability to pay? 1. Hormonal contraceptives Yes .................................................. 1 No ................................................... 0 b) 55 2. Condoms Yes .................................................. 1 No ................................................... 0 c) 55 2. STI treatment Yes .................................................. 1 No ................................................... 0 d) 55 3. HIV testing and counselling Yes .................................................. 1 No ................................................... 0 e) 55 4. Medical termination of pregnancy/abortion (where legal) Yes .................................................. 1 No ................................................... 0 Confident.......................................... 1 Somewhat/not confident.................. 0 Confident.......................................... 1 Somewhat/not confident.................. 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

24

27

How confident do you feel about your knowledge of how to provide care to adolescents? How comfortable do you feel in your ability to relate to adolescents and answer their questions? Did your mentor/supervisor ever observe a consultation by you with an adolescent client to help you to improve the quality of care? Did your mentor/supervisor ever advise you how to improve the quality of care for adolescent clients? Do you have a clear designation of responsibilities within the facility to ensure a welcoming and clean environment?

25

3

26

a)

66

b)

66

27

36

28 a)  43

Has any adolescent been denied services within last 12 months because of: Recent stock-outs? Yes .................................................. 1 No ................................................... 0

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 55

Question number b)  29 a) 

Criterion number 44 59

Questions for the health-care provider Malfunctioning/unavailable equipment? Is it possible to extract from your registers data on cause-specific service utilization by adolescents, along with the sex of adolescents? Do you report data on service utilization by adolescents, along with the sex of adolescents? Are you aware of any tools for selfmonitoring of the quality of care in the facility? Do you use these tools for selfmonitoring of quality for adolescent health services? Did you ever participate in facility meetings to analyse the results of the self-assessments and to plan actions for improvement of adolescent health care? Do you feel you have enough support from your supervisor to improve the quality of care for adolescents? Do you feel you have the motivation to improve the quality of care for adolescents, and to comply with quality standards? Have you, or any of your colleagues, ever been rewarded for high performance? If yes, what was the form of recognition?

Response & Code Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0

Remarks

è Skip to Q 30

b) 

68

30

a) 

61

è Skip to Q 31

b) 

64

31

a)

65

b)

70

Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 Performance incentives (monetary)... A Certificate.........................................B Award, such as Best performer of the month.........................................C Other (please specify).......................D ________________________________ è Skip to Q 33

c)

70

32

a)

67

b)

-

33

-

Do you do outreach work?

Yes .................................................. 1

No ................................................... 0

è Continue with the Q 34 è End the interview with thanks.

Questionnaire for the service provider who does outreach work

56 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 34 35 a)

Criterion number 5

Questions for the health-care provider Do you have a plan for outreach activities?

Response & Code Yes .................................................. 1 No ................................................... 0

Remarks

During the last 12 months, have you: 15 Participated in school meetings to inform parents/guardians and teachers about the health services available for adolescents, and why it is important that they use the services? Participated in meetings with youth and other community organizations to inform them about the health services available for adolescents and why it is important that adolescents use the services? Conducted any outreach sessions with adolescents to inform them about the services available? Conducted any outreach sessions with adolescents on health education about various topics? Yes .................................................. 1 No ................................................... 0

b)

16

Yes .................................................. 1 No ................................................... 0

c)

7

Yes .................................................. 1 No ................................................... 0 Yes .................................................. 1 No ................................................... 0 è End the interview with thanks.

d)

7

e)

7

What were the topics you discussed during these outreach sessions:

STI/HIV prevention............................ A Pregnancy prevention.......................B Use of contraceptives.......................C Healthy nutrition................................D Mental health promotion................... E Physical activity................................ F Immunization....................................G Menstrual hygiene............................H Antenatal care................................... I Sexual violence................................. J Bullying and school violence.............K Substance use and substance use disorders.......................................... L Injuries............................................. M Other (please specify).......................N ________________________________

End the interview with thanks. Notes for adaptation: 1 2

During the adaptation, such situations – e.g. sexual assaults, gunshot wounds, suicidal or homicide risk – should be listed. The appropriate age will be decided during the national adaptation, and it should be based on local statistics regarding the age of sexual initiation.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 57

SUPPORT STAFF INTERVIEW TOOL FACE SHEET Interviewee Code ____ ____ ____ ____ NAME OF THE PERSON: _________________________________________________ SEX: Male……1 Female……2

DESIGNATION: __________________________________________________________

NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 3 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

58 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

INTRODUCTION AND CONSENT Consent form for support staff

Hello, My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I would like to ask you some questions. This information will help to improve the quality of health care for adolescents in (the district, country) ______________________________. The interview will require about 10–15 minutes. All the information that you will provide in the interview will be kept confidential and not shared with anyone else. This survey is anonymous and the questionnaire will not be seen by anyone not involved in the survey analysis. Your participation in this review process is voluntary. You may decide not to participate in this interview or not to answer some of the questions.

Do you have any questions? May we begin?

Interviewee has agreed to participate

Yes......... 1

No.......... 2 Permission for observation is available Yes......... 1

No.......... 2

Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 59

SUPPORT STAFF INTERVIEW TOOL Question number 1 Criterion number Questions for support staff For how long have you been working in this health facility? What are you responsible for in this facility? Response & Code Remarks

____ ____ Years

/ ____ ____ Months

2

-

A Receptionist B Secretary C Cleaning staff D Security E Other (please specify) ....................................................

3

-

For how long have you been working in this position? Are health services for adolescents/youth being provided in this health facility? Have you received any training in providing services to adolescents?

____ ____ Years

/ ____ ____ Months

4

-

Yes ............................................1 No .............................................0 Don’t know.................................8 Yes ............................................1 No .............................................0

5

26

6 a) 3

Have you received any training/orientation on the following topics: How to communicate effectively with adolescent clients? What are the special needs of adolescent clients? The importance of having the same friendly attitude towards all adolescents irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other? The importance of respecting the rights of adolescents to information, privacy, confidentiality, and respectful care? Does your supervisor ever discuss your roles and responsibilities with you? Does your supervisor regularly provide supportive supervision to you for your work? Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0

b)

26

c)

26

d)

26

Yes ............................................1 No .............................................0

7

29

Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0

8

29

60 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 9

Criterion number 65

Questions for support staff Did you ever participate in facility meetings to discuss the quality of the services to adolescents and plan actions for improvement?

Response & Code Yes ............................................1 No .............................................0

Remarks

10 a) 36

Have you ever participated in meetings where you discussed with your manager and colleagues: How to make operating hours convenient for adolescents? How to minimize waiting time? How to keep the facility welcoming and clean? How to provide services to adolescents with or without an appointment? Did you ever participate in a facility self-assessment of the quality of care provided to adolescents? Do you feel you have enough support from your supervisor to improve the quality of care for adolescents? Do you feel you have the motivation to improve the quality of care for adolescents, and to comply with quality standards? Have you, or any of your colleagues, ever been rewarded for high performance? Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0 Yes ............................................1 No .............................................0

b) c) d)

36 36 36

11

a)

64

b)

70

c)

70

Yes ............................................1 No .............................................0

12

a)

67

Yes ............................................1 No .............................................0 è Skip to Q 13 if the interviewee is a receptionist. If not, end the interview with thanks.

b)

-

If yes, what was the form of recognition?

Performance incentives (monetary)................................. A Certificate.................................. B Award, such as Best performer of the month..................................... C Other (please specify)................ D _____________________________

End interview if the person is not a receptionist.

Continue with Q 13 if the interviewee is a receptionist.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 61

Question number

Criterion number

Questions for support staff

Response & Code

Remarks

Questions for the receptionist 13 41 Can adolescents have a consultation without an appointment? Is there a separate register for the registration of adolescents/youth? Are there separate columns for registering adolescents/youth in the common register? During the registration of adolescents/youth, can anyone else overhear your conversation? Do you think it is OK to tell the parents or teachers of an adolescent client about the problem he/she came to the facility with, without the adolescent knowing? Yes ............................................0 No .............................................1 Don’t know.................................8 Yes ............................................1 No .............................................0 Don’t know.................................8 Yes ............................................0 No .............................................1 Don’t know.................................8 Yes ............................................0 No .............................................1 Don’t know.................................8 Yes ............................................0 No .............................................1 Don’t know.................................8

14

59

15

59

16

42

17

38

End the interview with thanks.

62 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

ADULT CLIENT EXIT INTERVIEW TOOL FACE SHEET

Interviewee Code ____ ____ ____ ____ NAME OF THE PERSON: _________________________________________________ SEX: Male……1 Female……2

DESIGNATION: __________________________________________________________

NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 3 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 63

INTRODUCTION AND CONSENT Consent form for adult client exit interview

Hello, My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I would like to ask you some questions. This information will help to improve the quality of health care for adolescents in (the district, country) ______________________________. The interview will require about 10–15 minutes. All the information that you provide in the interview will be kept confidential and not shared with anyone else. This survey is anonymous and the questionnaire will not be seen by anyone not involved in the survey analysis. Your participation in this review process is voluntary. You may decide not to participate in this interview or not to answer some of the questions.

Do you have any questions? May we begin?

Interviewee has agreed to participate

Yes......... 1

No.......... 2 Permission for observation is available Yes......... 1

No.......... 2

Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________

64 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

ADULT CLIENT EXIT INTERVIEW TOOL Question number 1 Criterion number Questions for the adult client Why have you come to this health facility today? Response & Code To obtain services for my own health problem........................................1 I am accompanying another adult who is obtaining services ........................2 I am accompanying an adolescent who is obtaining services ........................3 2 a) Do you know if this facility provides services to adolescents and youth? Can you name some health services that are provided in this facility to adolescents and youth? (More than one answer is acceptable.) Yes .........................................................1 No ..........................................................0 Don’t know..............................................8 Services related to : Physical and pubertal development........ A Menstrual hygiene /problems.................. B Nutrition.................................................. C Anaemia................................................. D Immunization...........................................E STIs.........................................................F HIV......................................................... G Family planning/contraception ............... H Antenatal care..........................................I Safe delivery............................................J Postpartum care..................................... K Safe abortion...........................................L Post-abortion care..................................M Dermatological....................................... N Mental health.......................................... O Substance use....................................... P Violence................................................. Q Injuries.................................................... R Fever...................................................... S Diarrhoea.................................................T Malaria................................................... U Tuberculosis............................................V Other (please specify)............................ W ____________________________________ 3 a) 14 Has any service provider ever discussed with you the services available for adolescents and why it is important that adolescents use the services? Yes .........................................................1 No ..........................................................0 Can’t remember......................................7 Skip to Q 4 Skip to Q 3 Remarks

b)

-

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 65

Question number b)

Criterion number 14

Questions for the adult client During this discussion did the service provider give you any leaflets or other educational materials? Did you find these materials informative or useful? Have you ever attended any community or school meetings where the value of providing health services to adolescents or youth was discussed? Were any leaflets or other educational materials distributed in this meeting? Did you find these materials informative or useful? Do you know why it is important to provide services to adolescents, and that they use the services?

Response & Code Yes .........................................................1 No ..........................................................0 Can’t remember......................................7 Yes .........................................................1 No ..........................................................0 Can’t remember......................................7 Yes .........................................................1 No ..........................................................0 Don’t know..............................................8

Remarks

c)

14

4

a)

15

Skip to Q 5

b)

15

Yes .........................................................1 No ..........................................................0 Don’t know..............................................8 Yes .........................................................1 No ..........................................................0 Can’t remember......................................7 Yes .........................................................1 Code “yes” if at least 3 reasons1 listed in 5b are mentioned. Skip to Q 6 Skip to Q 5

c)

15

5

a)

17

No ..........................................................0 Can’t remember......................................7 b) Can you tell me why? Prevention of STIs and HIV.................... A Common conditions such as skin problems, headache, menstrual concerns, fatigue, scrotal pain or other....B Chronic conditions (HIV, mental health, diabetes, asthma) that need care and support................................................... C Contraceptive services........................... D High rate of adolescent pregnancies and births, and adolescents need access to ante-, intra- and postnatal care ...............E Adolescents are at risk of unsafe abortion, and need access to safe abortion services2 and post-abortion care.............F Substance use prevention, treatment and care................................................. G Nutrition problems (obesity, malnutrition, micronutrient deficiencies....................... H Cervical cancer prevention (HPV vaccine).. I Timely recognizing signs of depression and other mental health problems...........J Other (please specify)__________________ 66 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 6 a)

Criterion number

Questions for the adult client

Response & Code

Remarks

Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? 17 1. Hormonal contraceptives? Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 b) 17 2. Condoms? Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 c) 17 2. STI treatment? Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 d) 17 3. HIV testing and counselling? 3 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 e) 17 4. Medical termination of pregnancy/abortion (where legal)? 5. Mental health services Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 g) 17 6. Services in case of disclosure of violence? Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 h) 17 7. Nutrition services, for example anaemia treatment? Has any adolescent or young person from your family ever used health services from this health facility (including today)? Did any service provider in this health facility ever share any health information about that adolescent with you? 42 Did the health service provider get permission from that adolescent before disclosing this information to you? Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Not relevant (no adolescent in the family).......................................... 6 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 End the interview with thanks.

f)

17

7

a)

-

b)

c)

Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 67

Question number 8 a)

Criterion number -

Questions for the adult client Have you been present during the consultation with the adolescent today, or the last time the adolescent or young person from your family came here? Did the provider spent time alone with the adolescent towards the end of the consultation?

Response & Code Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Not relevant....................................... 6

Remarks

End the interview with thanks.

b)

42

Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8

End the interview with thanks. Notes for adaptation: 1 2 3

Other reasons might be added based on the local epidemiology during the national adaptation. In countries where abortion is legal. Countries should consider include also HIV treatment in this check list, as appropriate.

68 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

COVERAGE MEASUREMENT TOOLS

©NAFISE MOTLAQ/WORLD BANK

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 69

ADULT COMMUNITY MEMBER INTERVIEW TOOL FACE SHEET

NAME: _________________________________________________ SEX: Male……1 AGE: ____ ____ YEARS

Female……2

OCCUPATION: __________________________________________________________ ADDRESS: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 3 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

70 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

INTRODUCTION AND CONSENT Consent form for adult community member

Hello, My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I would like to ask you some questions. This information will help to improve the quality of health care for adolescents in (the district, country) ______________________________. The interview will require about 10–15 minutes. All the information that you provide in the interview will be kept confidential and not shared with anyone else. This survey is anonymous and the questionnaire will not be seen by anyone not involved in the survey analysis. Your participation in this review process is voluntary. You may decide not to participate in this interview or not to answer some of the questions.

Do you have any questions? May we begin?

Interviewee has agreed to answer

Yes......... 1

No.......... 2

Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 71

ADULT COMMUNITY MEMBER INTERVIEW TOOL Question number 1 a) Criterion number 17 Questions for the adult community member Do you know why it is important to provide services to adolescents, and why it is important that adolescents use the services? Response & Code Yes ................................................... 1 Remarks è Code “yes” if at least 3 reasons listed in 1b are mentioned.1 Skip to Q 2

No .................................................... 0 Can’t remember................................ 7 Prevention of STIs and HIV.............. A Common conditions such as skin problems, headache, menstrual concerns, fatigue, scrotal pain or other .............B Chronic conditions (HIV, mental health, diabetes, asthma) that need care and support.....................C Contraceptive services.....................D High rate of adolescent pregnancies and births, and adolescents need access to ante-, intra- and postnatal care .................................. E Adolescents are at risk of unsafe abortion, and need access to safe abortion services2 and postabortion care.................................... F Substance use prevention, treatment and care...........................G Nutrition problems (obesity, mal­ nu­ tri­ tion, micronutrient deficiencies...........H Cervical cancer prevention (HPV vaccine.............................................. I Timely recognizing signs of depression and other mental health problems.... J Other (please specify) ________________________________ Correct answer................................. 1 Doesn’t know or incorrect answer.... 0 Shop................................................ A Pharmacy.........................................B Government hospital/clinic/family planning centre.................................C Adolescent clinic...............................D Private hospital/clinic/family planning centre................................. E Community volunteer........................ F Auxiliary nurse midwife.....................G Other (please specify).......................H ________________________________ Yes ................................................... 1 No .................................................... 0 Can’t remember................................ 7

b)

17

Can you tell me why?

2

a)

17

Do you know where adolescents in this community can get health services?

(Probe for mention of services in the list.)

Code “correct answer” if at least 1 type of facility was named that is in line with national policy.3

3

a)

14

Has any service provider ever discussed with you the services available for adolescents and why it is important that adolescents use the services?

Skip to Q 4

72 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number b)

Criterion number 14

Questions for the adult community member During this discussion did the service provider give you any leaflets or other educational materials? Have you ever attended any community or school meetings where the value of providing health service to adolescents was discussed? Were any leaflets or other educational materials distributed in this meeting? Did you find these materials informative or useful?

Response & Code Yes ................................................... 1 No .................................................... 0 Can’t remember................................ 7 Yes ................................................... 1 No .................................................... 0 Can’t remember................................ 7

Remarks

4

a)

15

Skip to Q 5

b)

15

Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Can’t remember................................ 7

Skip to Q 5

c)

15

5 a) 17

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? ­ 1. Hormonal contraceptives? 2. Condoms? Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8 Yes ................................................... 1 No .................................................... 0 Don’t know........................................ 8

b)

17

c)

17

2. Treatment for sexually transmitted diseases? 3. HIV testing and counselling? 4. Medical termination of pregnancy/abortion (where legal)? 5. Mental health services?

d)

17

e)

17

f)

17

g)

17

6. Services in case of disclosure of violence? 7. Nutrition services, for example, anaemia ­treatment?

h)

17

End the interview with thanks. Notes for adaptation: 1 2 3

Other reasons might be added based on the local epidemiology during the national adaptation. In countries where abortion is legal. Adapt list according to the country policies.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 73

ADOLESCENT IN THE COMMUNITY INTERVIEW TOOL

Participant Code ____ ____ ____ ____ NAME OF THE FACILITY: ____________________________ CODE: ____ ____ ____ ____ ADDRESS OF FACILITY: Community _________________________________________ District/region _________________________________________ Province/zone _________________________________________ State _________________________________________ DATE OF INTERVIEW: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

RESULTS OF INTERVIEW: Completed.................. 1 Partially completed...... 2 Refused...................... 3 INTERVIEWED BY: ________________________________________________________________________________ TIME INTERVIEW BEGAN: ____ ____

:

____ ____

TIME INTERVIEW ENDED ____ ____

:

____ ____

HOUR MINUTE

HOUR MINUTE

Name and signature of supervisor ____________________________________________________________________ _________________________________________________________________________________________________

DATE CHECKED:

____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

74 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

INTRODUCTION AND CONSENT Consent form for parent(s)/guardian(s)/spouse accompanying an adolescent below the legal age of consent

Hello, My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in this facility on behalf of _____________________________. I am interested in your son’s/daughter’s/ward’s opinions, and I would like to talk to him/ her about his/her experience of using health-care services. For this I would like to ask him/ her a few questions. This information will help to improve health services for adolescents. This interview will take about 25–30 minutes. I will not write down his/her name and all the information he/she provides will be kept strictly confidential and not be shared with anyone else. His/her participation in this survey depends totally on you and him/her. If you wish you may refuse to give us permission to interview your son/daughter or ward. If you decide your son/ daughter/ward should not participate, it will not affect his/her access to services in any way.

Do you have any questions? May we begin?

The parent/guardian has given permission Yes......... 1 No.......... 2 “All my questions were answered. I have understood and agree to give consent to the interview.” Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________ DATE: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

Signature of interviewer: _________________________________________________________________________________________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 75

Consent form for adolescent client

My name is ___________________________________________________________ and I work for the ______________________________. We are conducting an assessment of the quality of care provided to adolescents in nearby facility(ies) on behalf of _____________________________. I am interested in your opinions, and I would like to talk to you about your experience of using health-care services. For this I would like to ask you a few questions. This information will help to improve health services for adolescents. This interview will take about 25–30 minutes. I will not write down your name, and all the information you provide will be kept strictly confidential and will not be shared with anyone else. Your participation in this survey depends totally on you (and your parent or guardian, if relevant). If you wish you may refuse to participate. If you choose not to participate, it will not affect your access to services in any way. If you do choose to be interviewed, you do not have to answer every question I ask you.

Do you have any questions? May we begin?

The interviewee has agreed to answer

Yes......... 1

No.......... 2 “All my questions were answered. I have understood and agree to give consent to the interview.” Signature/thumb impression/verbal consent of the interviewee: _________________________________________________________________________________________________ _________________________________________________________________________________________________ DATE: ____ ____

/ ____ ____ / ____ ____ ____ ____ M M Y Y Y Y

D D

Signature of interviewer: _________________________________________________________________________________________________

76 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

ADOLESCENT IN THE COMMUNITY INTERVIEW TOOL Section 1: Demographic Information Demographic Questions 1 How old are you? Response & Code ____ ____ Age in completed years Male....................................................1 Female................................................2 Christian..............................................1 Buddhist..............................................2 Hindu..................................................3 Islam...................................................4 Jew.....................................................5 Sikh.....................................................6 Other (please specify)........................10 __________________________________ Unmarried...........................................1 Married................................................2 Cohabiting...........................................3 Widow/widower..................................4 Divorced..............................................5 Separated...........................................6 Other (please specify)........................10 __________________________________ No education.......................................0 Primary completed..............................1 Primary (some.....................................2 Secondary completed.........................3 Secondary (some)................................4 College................................................5 University.............................................6 Master.................................................7 Vocational............................................8 Other (please specify)........................10 __________________________________ Student...............................................1 Housewife...........................................2 Service................................................3 Business..............................................4 Farming...............................................5 Other (please specify)........................10 __________________________________ Alone...................................................1 With family/parents..............................2 With husband......................................3 With friends.........................................4 Other (please specify)........................10 __________________________________ GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 77

Remarks

2 3

Sex What is your religion?

4

What is your present marital status?

5

What is the highest level of education that you have attained so far?

6

What do you currently do?

7

At present, whom do you live with?

ADOLESCENT IN THE COMMUNITY INTERVIEW TOOL Section 2: Knowledge and Perceptions about Adolescent Health-Care Services Question number 1 Criterion number Questions for the adolescent in the community In the past 6 months, have you visited any health facility or provider for health problems? Which type of health-care facility did you visit? Response & code Yes................................... 1 No.................................... 0 Don’t know....................... 8 Government facility........... A Private facility.................... B Charity facility...................C Other................................D (please specify) _______________________ 3 Which type of provider did you visit? General practitioner/family doctor.............................. A Paediatrician..................... B Gynaecologist...................C Nurse...............................D Midwife............................. E Community health worker.............................. F Pharmacist.......................G Other................................H (please specify) _______________________ 4 Which type of service did you go for? Physical and pubertal development.................... A Menstrual hygiene / problems.......................... B Nutrition............................C Anaemia...........................D Immunization.................... E STIs.................................. F HIV.................................. G Oral contraceptive pills.....H Condom.............................I IUD....................................J Emergency contraceptive pills............. K Contraceptive implant....... L Skip to Q 23 Remarks

2

-

78 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number

Criterion number

Questions for the adolescent in the community

Response & code Injectable contraception.... M Antenatal care..................N Safe delivery.....................O Postpartum care............... P Safe abortion....................Q Post-abortion care............ R Dermatological................. S Mental health.................... T Substance use.................U Violence........................... V Injuries............................. W Fever................................ X Diarrhoea.......................... Y Malaria............................. Z Tuberculosis................... ZZ Others ......................... ZZZ (please specify) _______________________

Remarks

5

a)

-

Did you tell your guardian (parent/ spouse/in-laws/other) about your visit?

Yes................................... 1 No.................................... 0 Can’t remember............... 7 è Skip to Q 5c è Skip to Q 6 Skip to Q6

b)

17

Did your guardian (parent/spouse/ in-laws/other) agree that you should attend? Why didn’t you tell?

Yes................................... 1 No.................................... 0 Can’t remember............... 7 For no particular reason..... A Fear of not being allowed to attend........................... B Wanted to keep it confidential.......................C Didn’t want to tell..............D Other................................ E (please specify) _______________________

c)

-

6

a)

-

If somebody accompanied you to the health facility, please state who it was.

Parents/guardian.............. 1 Friend............................... 2 Spouse............................. 3 Mother-in-law................... 4 Went alone....................... 5 Other.............................. 10 (please specify) _______________________

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 79

Question number b)

Criterion number 42, 47

Questions for the adolescent in the community If you were accompanied by another person, did you have some time alone with the healthcare provider? Was your visit to the nearby facility? (The nearby facility is the facility where the quality assessment is being conducted.) From whom did you hear about that health facility? (More than one answer is acceptable.)

Response & code Yes................................... 1 No.................................... 0 Yes................................... 1 No.................................... 0 Don’t know....................... 8 Peer/friend........................ A Parents/relatives............... B School..............................C Community volunteer........D Community health worker.... E Auxiliary nurse midwife..... F Doctor/medical officer......G Other................................H (please specify) _______________________

Remarks

7

Skip to Q 23

8

9

1

Did you notice any signboard in a language you understand that mentions the facility operating hours? Did you receive the health-care services that you went for?

Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Don’t know....................... 8 Skip to Q 12

10

23

11

a)

2

Did you see informational materials for adolescents, including video or TV, in the waiting area? Did you like the informational materials?

b)

2

12 a) 45

The last time you visited the nearby facility, did you find it had: Working hours that were convenient for you? Yes................................... 1 No.................................... 0 Can’t remember............... 7 b) 45 A reasonably short waiting time? (Ask how long the client waited.) Yes................................... 1 No.................................... 0 Can’t remember............... 7 Code “yes” if the waiting time was 30 minutes or less.

c)

42, 47

Curtains in doors and on windows so that nobody could see you during the examinations?

Yes................................... 1 No.................................... 0 Can’t remember............... 7

80 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number d)

Criterion number 46

Questions for the adolescent in the community Comfortable seating in the waiting area?

Response & code Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7

Remarks

e)

46

Drinking water available?

13 a) 46

Were the following sufficiently clean: The surroundings? Yes................................... 1 No.................................... 0 Can’t remember............... 7 b) 46 The consultation areas? Yes................................... 1 No.................................... 0 Can’t remember............... 7 c) 46 Toilets, which were functional? Yes................................... 1 No.................................... 0 Can’t remember............... 7

14

a)

52

Did you see a display which mentions that services will be provided to all adolescents without discrimination? Did you see a display with your rights?

Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Considerate, respectful and non-judgemental attitude............................. A Respect for privacy during consultations, exam­in­ations and treatments................. B Protection from physical and verbal assault.............C Confidentiality of information.......................D Non-discrimination........... E Participation..................... F Adequate and clear information ......................G Code “yes” if at least 3 mentioned from the list provided

b)

27

c)

34

Can you tell me what your rights are?

15

27

Did you see a display of the confidentiality policy?

Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7

16

32, 34

Was the service provider friendly to you?

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 81

Question number 17 a)

Criterion number 32, 34

Questions for the adolescent in the community Was the service provider respectful of what you needed?

Response & code Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Don’t know....................... 8

Remarks

b)

42

Did anyone else enter the room during your consultation?

18

a)

42

At the beginning of the consultation, did the service provider assure you that your information would not be shared with anyone without your consent? Did you feel confident that the information you shared with the service provider would not be shared with anyone else without your consent? Did you feel the information provided during the consultation was clear and that you understood it well? Did the provider ask you if you agreed with the treatment, procedure or solution that was proposed? Overall, did you feel that you were involved in the decision regarding your care – for example, did you have a chance to express your opinions or preferences for the care provided, and did you feel that your opinion was listened to, and heard? While you were at the facility, did you have any contact with anyone from support staff, such as the receptionist, cleaning staff or security staff? Did you feel that the support staff was friendly and treated you with respect? Did the service provider refer you to another health facility for services they did not provide there? Did he/she give you a detailed referral note, stating the condition, address for referral, operating hours and cost of services? Were you ever denied necessary services at the nearby facility?

b)

47

19

35, 75

20

a)

75

b)

78

21

a)

-

Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 1 No.................................... 0 Can’t remember............... 7 Yes................................... 0 No.................................... 1 Not relevant...................... 6 Skip to Q 24 Skip to Q 23 Skip to Q 22

b)

32, 34

22

a)

-

b)

22, 23

23

a)

57

82 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number b)

Criterion number 57

Questions for the adolescent in the community If yes, what do you think was the reason for being denied the services?

Response & code Age below 18................... A Unmarried........................ B Not in school....................C Unable to pay...................D Unavailable in the facility... E The condition needs referral.............................. F Other................................G (please specify) _______________________

Remarks

c)

57

Which services were denied?

Physical and pubertal development.................... A Nutritional......................... B Anaemia...........................C Immunization....................D Menstrual hygiene/ problems.......................... E RTI and STI...................... F HIV...................................G Oral contraceptive pills......H Condom.............................I IUD....................................J Emergency contraceptive pills............. K Implants........................... L Injectable contraception.................. M Medical abortion/menstrual regulation/surgical abortion....N Post-abortion care............O Antenatal care.................. P Postnatal care..................Q Dermatological................. R Mental health.................... S Substance use................. T Sexual violence.................U Other................................ V (please specify) _______________________

24

43, 48

Were you ever refused healthcare services in the nearby facility because of lack of medicines or other materials? Were you ever refused healthcare services in the nearby facility because lack of equipment, or because the equipment was not functioning?

Yes................................... 0 No.................................... 1 Don’t know....................... 8 Yes................................... 0 No.................................... 1 Don’t know....................... 8

25

44, 48

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 83

Question number 26 a)

Criterion number 6

Questions to adolescent in the community Did anybody tell you, that time or on other occasions, what other services you can obtain in the nearby facility? Could you tell me what (other) services are provided to adolescents in the nearby facility? (Probe for mention of services in the list.)

Response & code Yes.................................... 1 No..................................... 0 Can’t remember................ 7 Yes.................................... 1 No..................................... 0 Puberty and growth...........A Nutritional problems...........B Anaemia............................C Immunization.....................D Menstrual hygiene / problems........................... E RTI and STI....................... F HIV................................... G Oral contraceptive pills......H Condom............................ I IUD................................... J Contraceptive implants......K Injectable contraceptives..... L Emergency contraceptive pills.................................. M Safe abortion.....................N Post-abortion care............ O Antenatal care...................P Postnatal care.................. Q Skin diseases....................R Mental health.....................S Substance use.................. T Sexual violence..................U Other................................. V (please specify) _______________________

Skip

Skip to Q 27 Code “yes” if at least 2 (other) services are named apart from the service he/she came for.

b)

6

27

9

If one day you need services that are not provided in the nearby facility, do you know where to go, or whom to ask? Have you or your friends ever been approached to help staff in working with adolescents in the nearby facility? Have you or your friends ever been approached to help facility staff in planning health services, or any activity to improve the quality of services such as surveys, or participating in meetings to discuss the quality of care?

Yes.................................... 1 No..................................... 0 Yes.................................... 1 No..................................... 0 Yes.................................... 1 No..................................... 0

28

a)

79

b)

77

84 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 29

Criterion number 21, 23

Questions to adolescent in the community Have you ever received information, counselling or health services in the community setting, for example in schools, clubs, community meetings? Did you ever participate in any community sessions on health education organized by a community health worker or volunteer? What do you know about anaemia?

Response & code Yes.................................... 1 No..................................... 0 Can’t remember................ 7 Yes.................................... 1 No..................................... 0 Can’t remember................ 7 Nothing............................. 0 Satisfactory answer (yes)..... 1 Less haemoglobin/ blood.................................A It leads to: Weakness/tiredness..........B Loss of appetite.................C Repeated illness................D Slow growth and stunting.. E Other................................. F (please specify) _______________________

Skip

30

7

31

a)

8

è Skip to Q 32 Code “yes” if at least 2 items from the list were named.

b)

8

Do you know how to prevent anaemia?

Yes.................................... 1 No..................................... 0 Iron and folic acid tablets...............................A Eat leafy greens.................B Eat vegetables...................C Eat meat and liver..............D Drink milk.......................... E Eat eggs............................ F Have a balanced diet........ G Other.................................H (please specify) _______________________

Code “yes” if at least 2 methods from the list were named.

32

8

Can you name any health or other consequences of getting married very young?

Yes.................................... 1 No..................................... 0 Dropping out of school......A Early childbirth...................B More prone to sexually transmitted diseases..........C Other.................................D

Code “yes” if at least 2 consequences from the list were named.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 85

Question number 33 a)

Criterion number 8

Questions to adolescent in the community Can you name any health consequences of having a baby at a young age?

Response & code Yes................................ 1 No................................. 0 Anaemia........................ A Babies with low birth weight................... B Maternal death.............. C Difficult labour................ D Pre-term birth................ E Newborn death..............F Other.............................G (please specify) ______________________

Skip Code “yes” if named at least 2 consequences from the list provided.

b)

8

Do you know what is the minimum number of check-ups a pregnant women should have? (Ask 15–19 year olds only.)

Correct answer.............. 1 Doesn’t know or incorrect answer............ 0

Check the country policy for the recommended number of minimum check-ups.1 Code “correct answer” if at least 1 type of facility was named that is in line with national policy.2

c)

9

Do you know where an adolescent girl can go for such check-ups? (Ask 15–19 year olds only.)

Correct answer.............. 1 Doesn’t know or incorrect answer............ 0 Possible answers Government hospital..... A Adolescent clinic............ B Health centre/offices...... C Auxiliary nurse midwife.. D Private hospital.............. E Other..............................F (please specify) ______________________

86 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 34 a)

Criterion number 8

Questions to adolescent in the community Can you name any methods of contraception or family planning? (Ask 15–19 year olds only.)

Response & code Yes................................ 1 No................................. 0 Condom........................ A Oral contraceptive pills... B Emergency contraceptive pills.......... C IUD................................ D Injectables..................... E Implants........................ E Abstinence.....................F LAM..............................G Standard Days Method... H Withdrawal......................I Others (please specify)....J ______________________

Skip

è Skip to Q 35

Code “yes” if at least 3 methods from the list below were named, with at least 2 modern methods.

b)

9

Do you think you could obtain a method if you needed one? (Ask 15–19 year olds only.)

Yes................................ 1 No................................. 0 Yes................................ 1 No................................. 0 Stopping a pregnancy from happening............. 1 No................................. 0 Other........................... 10 (please specify) ______________________ Yes................................ 1 No................................. 0 è Skip to Q 35

c)

8

Have you heard about emergency contraceptive pills? (Ask 15–19 year olds only.)

d)

8

Do you know what they are used for? (Ask 15–19 year olds only.) (Probe for what they are used for.)

e)

9

Do you think you could obtain them if you needed them? (Ask 15–19 year olds only.)

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 87

Question number 35 a)

Criterion number 8

Questions to adolescent in the community Have you heard about condoms? (Ask 15–19 year olds only.)

Response & code Yes................................ 1 No................................. 0 Yes................................ 1 No................................. 0 Don’t know.................... 8 For contraception/ preventing pregnancy.... A Preventing HIV............... B Other............................. C (please specify) ______________________

Skip

è Skip to Q 36 Code “yes” if both pregnancy and STIs prevention is mentioned.

b)

8

Could you tell me why a condom is used? (Ask 15–19 year olds only.) (Probe for what they are used for.)

c)

9

If you or your friends needed a condom, do you know where to get them? (Ask 15–19 year olds only.) (Probe for where to get condoms.)

Yes................................ 1 No................................. 0 Shop............................. A Pharmacy...................... B Government hospital / clinic/family planning centre............................ C Adolescent clinic............ D Private hospital/clinic/ family planning centre.... E Community volunteer......F Auxiliary nurse midwife..G Other............................. H (please specify) ______________________

Code “yes” if at least one place is mentioned.

d)

21

Do you feel you could get a condom if you needed one? (Ask 15–19 year olds only.)

Yes................................ 1 No................................. 0 Don’t know.................... 8

88 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Question number 36 a)

Criterion number 8

Questions to adolescent in the community Have you heard of HIV?

Response & code Yes................................ 1 No................................. 0

Skip

Skip to Q 37 Code “yes” if all five questions are answered correctly.

b)

8

Could you please answer the following questions on HIV?

Yes................................ 1 No................................. 0 Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners?....................... A Can a person reduce the risk of getting HIV by using a condom every time they have sex?....... B Can a healthy-looking person have HIV?.......... C Can a person get HIV from mosquito bites?..... D Can a person get HIV by sharing food with someone who is infected?...... E

c)

9

If you would want to get tested for HIV, do you know where you can readily get an HIV test? If an adolescent in your locality had an unwanted pregnancy, would they know where to go for medical advice? Do you know what care to take each month during the menstrual cycle? (Ask this question to girls only.)

Yes................................ 1 No................................. 0 Yes................................ 1 No................................. 0 Don’t know.................... 8 Yes................................ 1 No................................. 0 Daily shower.................. A Use soft and clean cloth.............................. B Wash cloth with soap and water...................... C Dry cloth in sunlight....... D Store cloth in clean place............................. E Use sanitary napkins.......F How to dispose of sanitary napkins.............G Other............................. H (please specify) ______________________ Code “yes” if at least two items from the list were named.

37

9

38

8

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 89

Question number 39 a)

Criterion number 8

Questions to adolescent in the community Have you ever heard of diseases that can be transmitted through sexual intercourse? (Ask 15–19 year olds only.)

Response & code Yes................................ 1 No................................. 0 Don’t know.................... 8 Yes................................ 1 No................................. 0 Abdominal pain (only in women...................... A Genital discharge........... B Foul-smelling discharge.. C Burning pain on urination.D Genital ulcers/sores....... E Swellings in groin area....F Other.............................G (please specify) ______________________

Skip

Skip to Q 40 Code “yes” if at least one correct symptom is named.

b)

8

Do you know any symptoms of sexually transmitted infections? (Ask 15–19 year olds only.)

c)

9

If you or someone of your age had these problems, would you know where to go for a check-up and treatment? (Probe for where to go for checkup and treatment.)

Yes................................ 1 No ................................ 0 Self-treat........................ A Traditional healer............ B Adolescent clinic............ C Government facility........ D Auxiliary nurse midwife.. E Private clinic...................F Other.............................G (please specify) ______________________

Code “yes” if at least one healthcare facility is named.

40

a

-

Do you have some ideas for how adolescents can get more involved in planning designing and implementing good quality health care in this community? Can you please share your ideas with us?

Yes................................ 1 No................................. 0 è End the interview with thanks.

b

-

______________________ ______________________ ______________________ ______________________

End the interview with thanks. Notes for adaptation: 1 2

Adapt according to the country policies; WHO-recommended minimum number of antenatal visits is four. Adapt list according to the country policies.

90 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 91

For more information, please contact: Department of Maternal, Newborn, Child and Adolescent Health (MCA) World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland Tel.: +41 22 791 3281 Fax: +41 22 791 4853 Email: mncah@who.int www.who.int/maternal_child_adolescent/en

ISBN 978 92 4 154933 2



GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A GUIDE TO IMPLEMENT A STANDARDS-DRIVEN APPROACH TO IMPROVE THE QUALITY OF HEALTH-CARE SERVICES FOR ADOLESCENTS

Volume 4: Scoring sheets for data analysis

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS A guide to implement a standards-driven approach to improve the quality of health-care services for adolescents

Volume 4: Scoring sheets for data analysis

©MARTINE PERRET/UNMIT

WHO Library Cataloguing-in-Publication Data Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents. Volume 4: Scoring sheets for data analysis 4 v. Contents: Volume 1: Standards and criteria - Volume 2: Implementation guide - Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards Volume 4: Scoring sheets for data analysis 1.Adolescent Health Services – standards. 2.Quality of Health Care. 3.Adolescent. 4.Data Collection. 5. Health Care Surveys – methods. 6.National Health Programs. I.World Health Organization. ISBN 978 92 4 154933 2 (NLM classification: WA 330)

© World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/ about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland Cover photo: Camila Eugenia Vargas Design by Inís Communication – www.iniscommunication.com

CONTENTS Acknowledgments Abbreviations Introduction Scoring sheets for data analysis v vi 1 2

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS iii ©AMJAD JAMAL/UN PHOTO

©MARCO DORMINO/UN PHOTO

ACKNOWLEDGMENTS The World Health Organization (WHO) is grateful to UNAIDS and all those who gave technical input into the production of this document. Lead writers: Subidita Chatterjee (independent consultant) and Valentina Baltag (WHO). WHO working group: Paul Bloem, Krishna Bose (formerly WHO), Venkatraman Chandra-Mouli, Charlotte Christiansen (formerly WHO), Jane Ferguson, Nuhu Yaqub.  Peer review (WHO): Anastasyia Dumcheva, (WHO Country Office in Ukraine), Symplice Mbola Mbassi (WHO Regional Office for Africa), Howard Sobel (WHO Regional Office for the Western Pacific). Peer review (UNAIDS): staff members. Peer review (external review group): Regina Benevides (Evidence to Action, United States of America), Doortje Braeken (International Planned Parenthood Federation, United Kingdom), Scott Burnett (loveLife, South Africa), Danielle Engel (United National Population Fund, United States of America), Mychelle Farmer (Jhpiego, United States of America), Bamikale Feyisetan (Evidence to Action, United States of America), Gwyn Hainsworth (Pathfinder International, United States of America), Jari Kempers (Qalys Health Economics, Estonia), Vijay Kumar (Survival for Women and Children Foundation, India), Catherine Lane (United States Agency for International Development, United States of Amercia), Laura Laski (United National Population Fund, United States of America), Galina Lesco (National Resource Centre in YFHS “Neovita”, Republic of Moldova), Ricky Lu (Jhpiego, United States of America), Elizabeth Mapella (Ministry of Health, United Republic of Tanzania), Edgar Necochea (Jhpiego, United States of America), Beth Outterson (Save the Children, United States of America), Elizabeth Saewyc (University of British Columbia, Canada), Olena Sakovych (United Nations Children’s Fund, Ukraine), Susan Sawyer (University of Melbourne, Australia), Kat Watson (International Planned Parenthood Federation, United Kingdom), Sylvia Wong (United National Population Fund, United States of America). Editing: Jura Editorial Services, Gex, France.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS v

ABBREVIATIONS HMIS NGO SOP WHO health management information systems nongovernmental organizations standard operating procedure World Health Organization

vi GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS ©NICK VAN PRAAG/THE WORLD BANK

INTRODUCTION This document is part of the Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health-care services for adolescents. It is one of four volumes published separately, which include: • Volume 1: Standards and criteria • Volume 2: Implementation guide • Volume 3: Tools to conduct quality and coverage measurement surveys to collect data about compliance with the global standards • Volume 4: Scoring sheets for data analysis This volume, Scoring sheets for data analysis, is to be used in conjunction with the monitoring tools in Volume 3. Using this data analysis method, countries can determine compliance with quality standards. How to use this volume: The scoring sheets in this volume are organized by criterion. There is a separate scoring sheet for each criterion. The total scores for all the criteria that apply to a standard are averaged to yield an overall score for that standard.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 1

SCORING SHEETS FOR DATA ANALYSIS (click on the criterion’s number to go directly to its scoring sheet)

Criterion 1. 3 Criterion 2. 4 Criterion 3. 5 Criterion 4. 6 Criterion 5. 7 Criterion 6. 7 Criterion 7. 9 Criterion 8. 10 Criterion 9. 13 Criterion 10. 15 Criterion 11. 16 Criterion 12. 17 Criterion 13. 17 Criterion 14. 18 Criterion 15. 19 Criterion 16. 21 Criterion 17. 21 Criterion 18. 24 Criterion 19. 25 Criterion 20. 26 Criterion 21. 28 Criterion 22. 36 Criterion 23. 37 Criterion 24. 38 Criterion 25. 40 Criterion 26. 41 Criterion 27. 43

Criterion 28. 45 Criterion 29. 52 Criterion 30. 53 Criterion 31. 54 Criterion 32. 62 Criterion 33. 65 Criterion 34. 65 Criterion 35. 66 Criterion 36. 67 Criterion 37. 70 Criterion 38. 71 Criterion 39. 74 Criterion 40. 75 Criterion 41. 76 Criterion 42. 77 Criterion 43. 81 Criterion 44. 84 Criterion 45. 86 Criterion 46. 87 Criterion 47. 88 Criterion 48. 90 Criterion 49. 91 Criterion 50. 92 Criterion 51. 93 Criterion 52. 94 Criterion 53. 95 Criterion 54. 95

Criterion 55. 96 Criterion 56. 97 Criterion 57. 97 Criterion 58. 98 Criterion 59. 98 Criterion 60. 100 Criterion 61. 101 Criterion 62. 102 Criterion 63. 102 Criterion 64. 103 Criterion 65. 104 Criterion 66. 105 Criterion 67. 107 Criterion 68. 107 Criterion 69. 108 Criterion 70. 109 Criterion 71. 110 Criterion 72. 110 Criterion 73. 111 Criterion 74. 112 Criterion 75. 113 Criterion 76. 115 Criterion 77. 116 Criterion 78. 117 Criterion 79. 118

2 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 1. The health facility has a signboard that mentions operating hours.

Adolescent client exit interview tool Number 2 Question Did you notice any signboard in a language you understand that mentions the operating hours of the facility? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Direct observation (checklist) tool Number 1a 1b 1c Question Is there a signboard that mentions the facility operating hours? Is it clearly visible? Does it mention hours for adolescent health clinics? Response 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Total score

Aggregate direct observation (checklist) score

Adolescent in the community interview tool Number 9 Question Did you notice any signboard in a language you understand that mentions the facility operating hours? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 1 Category 1 2 3 Aggregate adolescent client score Aggregate direct observation (checklist) score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–3 0–1 0–5 0 to 100% Score

Absolute total score Relative score for Criterion 1

(

Total score 5

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 3

CRITERION 2. The health facility has in the waiting area up-to-date information, education and communication materials specifically developed for adolescents. Adolescent client exit interview tool Number 11a Question Did you see informational materials for adolescents, including video or TV, in the waiting area? Did you like the informational materials? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

11b

1=Yes, 0=No, 8=Don’t know

Aggregate adolescent client score

Direct observation (checklist) tool Number 2b Question Does the waiting area have information, education and communication materials specifically developed for adolescents? Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

Adolescent in the community interview tool Number 11a Question Did you see informational materials for adolescents, including video or TV, in the waiting area? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total score

11b

Did you like the informational materials?

1=Yes, 0=No, 8=Don’t know

Aggregate adolescent in the community score

Overall score on Criterion 2 Category 1 2 3 Aggregate adolescent client score Aggregate direct observation (checklist) score Aggregate adolescent in the community score Minimum – Maximum 0–2 0–1 0–2 0–5 0 to 100% Score

Absolute total score Relative score for Criterion 2

(

Total score 5

)

× 100

4 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 3. Health-care providers have competencies to provide health education to adolescents and to communicate about health and available services (health, social and other services). Health facility manager interview tool Number 3a Question Could you tell me which of these components were covered by the training in adolescent health? Communication skills to talk to adolescents Aggregate health facility manager score Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of managers interviewed Total score

Direct observation (checklist) tool Number 13a Question Check to see training records/reports for the following topics. Communication skills to talk to adolescents Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 4a Question Have you received the following training in adolescent health care: Communication skills to talk to adolescents? 25 How comfortable do you feel in your ability to relate to adolescents and answer their questions? 1=Confident, 0=Somewhat/not confident Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number responses coded “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Support staff interview tool Number 6a Question Have you received any training/ orientation on the following topics: How to communicate effectively with adolescent clients? Aggregate support staff score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 5

Overall score on Criterion 3 Category 1 2 3 4 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–1 0–1 0–2 0–1 0–5 0 to 100% Score

Absolute total score Relative score for Criterion 3

(

Total score 5

)

× 100

CRITERION 4. The health facility has outreach workers that are trained to conduct health education for adolescents in the community. Direct observation (checklist) tool Number 13h Question Check to see training records/reports for the following topics. Training of outreach workers in adolescent health care Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 15a Question Have you ever trained any of the following groups in these areas: Outreach workers in adolescent health care? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 4 Category 1 2 Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 4

(

Total score 2

)

× 100

6 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 5. The health facility has a plan for outreach activities and/or involvement of outreach workers in activities to promote health and increase adolescents’ use of services. Health facility manager interview tool Number 16b Question Does the facility have a documented plan: To inform adolescents in the community (in schools, clubs, community meetings) about their health and the services available? Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of managers interviewed Total score

Health-care provider interview tool Number 34 Question Do you have a plan for outreach activities? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 5 Category 1 2 Aggregate facility manager score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 5

(

Total score 2

)

× 100

CRITERION 6. Health-care providers provide age and developmentally appropriate health education and counselling to adolescent clients and inform them about the availability of health, social services and other services. Adolescent client exit interview tool Number 8 Question Did anybody tell you, today or in other occasions, what other services you can obtain in this facility? Did any service provider talk to you about how to prevent diseases and what to do to stay healthy? Response 1=Yes, 0=No Score Total number of responses coded “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

17a

1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 7

Number 17b

Question Did the service provider inform you about the services available?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Direct observation (client-provider interaction) tool Number 16b Question During the consultation did the service provider do the following: Talk about how to prevent diseases and what to do to stay healthy? 16c During the consultation did the service provider do the following: Inform the adolescent client about the services available for him/her? Aggregate direct observation (client-provider interaction) score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total score

Health-care provider interview tool Number 20 Question Do you inform adolescents about the availability of health, social services and other services available? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Adolescent in the community interview tool Number 26a Question Did anybody tell you, that time or on other occasions, what other services you can obtain in the nearby facility? Could you tell me what (other) services are provided to adolescents in the nearby facility? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total score

26b

1=Yes, 0=No

Aggregate adolescent in the community score

8 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 6 Category 1 2 3 4 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–3 0–2 0–1 0–2 0–8 0 to 100% Score

Absolute total score Relative score for Criterion 6

(

Total score 8

)

× 100

CRITERION 7. Outreach activities to promote health and increase adolescents’ use of services are carried out according to the health facility’s plan. Direct observation (checklist) tool Number 9e Question Check to see the following registers, tools and records. Register/records of accomplished outreach activities to inform adolescents in community settings Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 35c Question During the last 12 months, have you: Conducted any outreach sessions with adolescents to inform them about the services available? 35d During the last 12 months, have you: Conducted any outreach sessions with adolescents on health education about various topics? Aggregate health-care provider score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Adolescent in the community interview tool Number 30 Question Did you ever participate in any community sessions on health education organized by a community health worker or volunteer? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 9

Overall score on Criterion 7 Category 1 2 3 Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–2 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 7

(

Total score 4

)

× 100

CRITERION 8. Adolescents are knowledgeable about health. Adolescent client exit interview tool Number 25a Question What do you know about anaemia? Response 1=Satisfactory answer (yes), 0=No Score Total number of responses coded “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0”

25b

Do you know how to prevent anaemia?

1=Yes, 0=No

26a

Can you name any health or other consequences of getting married very young?

1=Yes, 0=No

26b

Can you name any health consequences of having a baby at a young age?

1=Yes, 0=No

27a

Do you know what is the minimum number of check-ups that a pregnant woman should get? (Ask 15–19 year olds only.) Can you name any methods of contraception? (Ask 15–19 year olds only.) Have you ever heard about emergency contraceptive pills? (Ask 15–19 year olds only.) Do you know what they are used for? (Ask 15–19 year olds only.)

1=Correct answer, 0= Doesn’t know or incorrect answer 1=Yes, 0=No

28a

28c

1=Yes, 0=No

28d

1= Stopping a pregnancy from happening, 0=No, 10= Other (please specify)

10 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 29a

Question Have you heard about condoms? (Ask 15–19 year olds only.)

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

29b

Could you tell me why a condom is used? (Ask 15–19 year olds only.)

1=Yes, 0=No

30a

Have you heard of HIV?

1=Yes, 0=No

30b

Could you please answer the following questions on HIV?

1=Yes, 0=No

32

Do you know what care to take each month during the menstrual cycle? (Ask girls only.) Have you ever heard of diseases that can be transmitted through sexual intercourse? (Ask 15–19 year olds only.) Do you know any symptoms of sexually transmitted infections? (Ask 15–19 year olds only.)

1=Yes, 0=No

33a

1=Yes, 0=No

33b

1=Yes, 0=No

Aggregate adolescent client score Adolescent in the community interview tool Number 31a Question What do you know about anaemia? Response 1=Satisfactory answer (yes), 0=Nothing

Score Total number of responses coded “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the total number of adolescents in the community interviewed

31b

Do you know how to prevent anaemia?

1=Yes, 0=No

32

Can you name any health or other consequences of getting married very young?

1=Yes, 0=No

33a

Can you name any health consequences of having a baby at a young age?

1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 11

Number 33b

Question Do you know what is the minimum number of check-ups that a pregnant woman should get? (Ask 15–19 year olds only.) Can you name any methods of contraception or family planning? (Ask 15–19 year old only.) Have you ever heard about emergency contraceptive pills? (Ask 15–19 year olds only.) Do you know what they are used for? (Ask 15–19 year olds only.)

Response 1=Correct answer, 0= Doesn’t know or incorrect answer 1=Yes, 0=No

Score Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total score

34a

34c

1=Yes, 0=No

34d

1= Stopping a pregnancy from happening, 0=No, 10= Other (please specify) _________ 1=Yes, 0=No

35a

Have you heard about condoms? (Ask 15–19 year olds only.)

35b

Could you tell me why a condom is used? (Ask 15–19 year olds only.)

1=Yes, 0=No

36a

Have you heard of HIV?

1=Yes, 0=No

36b

Could you please answer the following questions on HIV?

1=Yes, 0=No

38

Do you know what care to take each month during the menstrual cycle? (Ask girls only.) Have you ever heard of diseases that can be transmitted through sexual intercourse? (Ask 15–19 year olds only.) Do you know any symptoms of sexually transmitted infections? (Ask 15–19 year olds only.)

1=Yes, 0=No

39a

1=Yes, 0=No

39b

1=Yes, 0=No

Aggregate adolescent in the community score

12 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 8 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–15 0–15 0–30 0 to 100% Score

Absolute total score Relative score for Criterion 8

(

Total score 30

)

× 100

CRITERION 9. Adolescents are aware of what health services are being provided, where and when they are provided and how to obtain them. Adolescent client exit interview tool Number 9 Question Could you tell me what (other) services are provided to adolescents in this facility? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded “1” divided by the sum of responses coded “1” and “0”

10

If one day you will need services that are not provided in this facility, do you know where to go, or whom to ask? Do you know where an adolescent girl can go for such check-ups? (Ask 15–19 year olds only.)

1=Yes, 0=No

27b

1=Correct answer, 0=Doesn’t know or incorrect answer 1=Yes, 0=No

28b

Do you think you could get one if you needed it? (Ask 15–19 year olds only.) Do you think you could get them if you needed them? (Ask 15–19 year olds only.) If you or your friends would need a condom, can you tell me where to get one? (Ask 15–19 year olds only.) If you would want to get tested for HIV would you be able to get tested?

Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the total number of adolescents clients interviewed Total score

28e

1=Yes, 0=No

29c

1=Yes, 0=No

30c

1=Yes, 0=No

31

If an adolescent in your locality had an unwanted pregnancy, would they know where to go for medical advice? If you or someone of your age had these problems, would you know where to go for check-up and treatment?

1=Yes, 0=No, Don’t know=8 1=Yes, 0=No, Don’t know=8

33c

Aggregate adolescent client score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 13

Adolescent in the community interview tool Number 27 Question If one day you will need services that are not provided in this facility, do you know where to go, or whom to ask? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded “1” divided by the sum of responses coded “1” and “0” Total number of responses coded “1” divided by the total number of adolescents in the community interviewed Total score

33c

Do you know where an adolescent girl can go for such check-ups? (Ask 15–19 year olds only.) Do you think you could obtain a method if you needed one? (Ask 15–19 year olds only.) Do you think you could obtain them if you needed them? (Ask 15–19 year olds only.) If you or your friends needed a condom, do you know where to get them? (Ask 15–19 year olds only.) If you would want to get tested for HIV, do you know where you can readily get an HIV test?

1=Correct answer, 0=Doesn’t know or incorrect answer 1=Yes, 0=No

34b

34e

1=Yes, 0=No

35c

1=Yes, 0=No

36c

1=Yes, 0=No

37

If an adolescent in your locality had an unwanted pregnancy, would they know where to go for medical advice? If you or someone of your age had these problems, would you know where to go for check-up and treatment?

1=Yes, 0=No, 8=Don’t know

39c

1=Yes, 0=No, 8=Don’t know

Aggregate adolescent in the community score

Overall score on Criterion 9 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–9 0–8 0–17 0 to 100% Score

Absolute total score Relative score for Criterion 9

(

Total score 17

)

× 100

14 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 10. Health-care providers have competencies and support materials to communicate with parents, guardians and other community members and organizations about the value of providing health services to adolescents. Health facility manager interview tool Number 3b Question Could you tell me which of these components were covered by training in adolescent health? Communication skills to talk to adult visitors/community members Aggregate health facility manager score Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded “1” divided by the sum of responses coded “1” and “0”

Total score

Direct observation (checklist) tool Number 13b Question Check to see training records/reports for the following topics. Communication skills to talk to adult visitors and community members Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 4b Question Have you received the following training in adolescent health care: Communication skills to talk to adolescents? 19 Do you have support materials to communicate with parents, guardians and other community members and organizations about the value of providing health services to adolescents? 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 10 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–2 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 10

(

Total score 4

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 15

CRITERION 11. The health facility has an updated list of agencies and organizations with which it partners to increase community support for adolescents’ use of services. Health facility manager interview tool Number 18a Question Do you have at hand updated lists of: Agencies and organizations the facility partners with to increase community support for adolescent use of services? Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 15a Question Check the availability of the following lists. Updated list of agencies and organizations with which the facility partners to increase community support for adolescent use of services Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Overall score on Criterion 11 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 11

(

Total score 2

)

× 100

16 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 12. The health facility has a plan for outreach activities and/or involvement of outreach workers in activities to increase gatekeepers’ support for adolescents’ use of services. Health facility manager interview tool Number 16a Question Does the facility have a documented plan: To inform adults, when they visit the health facility, during community meetings and through community organizations, about the value of providing services to adolescents? Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Overall score on Criterion 12 Category 1 Aggregate facility manager score Minimum – Maximum 0–1 0–1 0 to 100% Score

Absolute total score Relative score for Criterion 12

(

Total score 1

)

× 100

CRITERION 13. The health facility engages in partnerships with adolescents, gatekeepers and community organizations to develop health education and behaviour-oriented communication strategies and materials and plan service provision. Direct observation (checklist) tool Number 9h Question Check to see the following registers, tools and records. Record(s) of formal agreements/partnerships with community organizations to develop health education and behavior-oriented communications strategies and materials, and plan service provision Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 17a Question Have you ever worked with: Agencies and organizations in the community to develop health education and behaviour-oriented communication strategies and materials and plan service provision? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 17

Overall score on Criterion 13 Category 1 2 Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 13

(

Total score 2

)

× 100

CRITERION 14. Health-care providers inform parents/guardians visiting the health facility about the value of providing health services to adolescents. Health-care provider interview tool Number 18 Question Do you inform adults visiting the health facility about services available for adolescents, and why it is important that adolescents use the services? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Adult client exit interview tool Number 3a Question Has any service provider every discussed with you the services available for adolescents and why it is important that adolescents use the services? During this discussion did the service provider give you any leaflets or other educational materials? Did you find these materials informative or useful? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

3b

1=Yes, 0=No, 7=Can’t remember

3c

1=Yes, 0=No, 7=Can’t remember

Aggregate adult client score

Adult community member interview tool Number 3a Question Has any service provider every discussed with you the services available for adolescents and why it is important that adolescents use the services? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

18 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 3b

Question During this discussion did the service provider give you any leaflets or other educational materials?

Response 1=Yes, 0=No, 7=Can’t remember

Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adult community member score

Overall score on Criterion 14 Category 1 2 3 Aggregate health-care provider score Aggregate adult client score Aggregate adult community member score Minimum – Maximum 0–1 0–3 0–2 0–6 0 to 100% Score

Absolute total score Relative score for Criterion 14

(

Total score 6

)

× 100

CRITERION 15. Health-care providers and/or outreach workers inform parents/guardians and teachers during school meetings about the value of providing health services to adolescents. Direct observation (checklist) tool Number 9g Question Check to see the following registers, tools and records. Register/records of accomplished outreach activities to inform parents/guardians and teachers during school meetings about the value of providing health services to adolescents Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 35a Question During the last 12 months, have you: Participated in school meetings to inform parents/guardians and teachers about the health services available for adolescents, and why it is important that they use the services? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 19

Adult client exit interview tool Number 4a Question Have you ever attended any community or school meetings where the value of providing health services to adolescents or youth was discussed? Were any leaflets or other educational materials distributed in this meeting? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

4b

1=Yes, 0=No, 7=Can’t remember

4c

Did you find these materials informative or useful?

1=Yes, 0=No, 7=Can’t remember

Aggregate adult client score

Adult community member interview tool Number 4a Question Have you ever attended any community or school meetings where the value of providing health service to adolescents was discussed? Were any leaflets or other educational materials distributed in this meeting? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

4b

1=Yes, 0=No, 8=Don’t know

4c

Did you find these materials informative/ useful?

1=Yes, 0=No, 7=Can’t remember

Aggregate community member score

Overall score on Criterion 15 Category 1 2 3 4 Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate adult client score Aggregate adult community member score Minimum – Maximum 0–1 0–1 0–3 0–3 0–8 0 to 100% Score

Absolute total score Relative score for Criterion 15

(

Total score 8

)

× 100

20 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 16. Health-care providers and/or outreach workers inform youth and other community organizations about the value of providing health services to adolescents. Direct observation (checklist) tool Number 9f Question Check to see the following registers, tools and records. Register/records of accomplished outreach activities to inform youth and other community organizations about the value of providing health services to adolescents. Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 37b Question During the last 12 months, have you: Participated in meetings with youth and other community organizations to inform them about the health services available for adolescents and why it is important that adolescents use the services? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Overall score on Criterion 16 Category 1 2 Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 16

(

Total score 2

)

× 100

CRITERION 17. Gatekeepers and community organizations support the provision of health services to, and their utilization by, adolescents. Adolescent client exit interview tool Number 5 Question Does your guardian (parent/spouse/inlaws/other) support your using this health facility? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 21

Adult client exit interview tool Number 5a Question Do you know why it is important to provide services to adolescents, and that they use the services? Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? Hormonal contraceptives? 6b Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? Condoms? 6c Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? STI treatment? 6d Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? HIV testing and counselling? 6e Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? Medical termination of pregnancy/abortion (where legal)? 6f Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? Mental health services? 6g Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? Services in case of disclosure of violence? 6h Do you agree that following services should be provided to all adolescents regardless of sex, age or marital status? Nutrition services, for example anaemia treatment? Aggregate adult client score 1=Yes, 0=No, 8=Don’t know 1=Yes, 0=No, 8=Don’t know 1=Yes, 0=No, 8=Don’t know 1=Yes, 0=No, 8=Don’t know 1=Yes, 0=No, 8=Don’t know 1=Yes, 0=No, 8=Don’t know 1=Yes, 0=No, 8=Don’t know Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed

6a

1=Yes, 0=No, 8=Don’t know

Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed Total number of responses coded as “1” divided by the total number of adult clients interviewed

Total score

22 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Adult community member interview tool Number 1b Question Do you know why it is important to provide services to adolescents, and why it is important that adolescents use the services? Can you tell me why? Do you know where adolescents in this community can get health services? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded “1” divided by the total number of adult community members interviewed Total number of responses coded “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total number of responses coded as “1” divided by the total number of adult community members interviewed Total score

2a

1=Correct answer, 0=Doesn’t know or incorrect

5a

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Hormonal contraceptives?

1=Yes, 0=No, 8=Don’t know

5b

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Condoms?

1=Yes, 0=No, 8=Don’t know

5c

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Treatment for sexually transmitted diseases?

1=Yes, 0=No, 8=Don’t know

5d

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? HIV testing and counselling?

1=Yes, 0=No, 8=Don’t know

5e

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Medical termination of pregnancy/abortion (where legal)?

1=Yes, 0=No, 8=Don’t know

5f

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Mental health services?

1=Yes, 0=No, 8=Don’t know

5g

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Services in case of disclosure of violence?

1=Yes, 0=No, 8=Don’t know

5h

Do you agree that the following services should be provided to adolescents irrespective of age or marital status? Nutrition services, for example, anaemia treatment?

1=Yes, 0=No, 8=Don’t know

Aggregate adult community member score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 23

Adolescent in the community interview tool Number 5b Question Did your guardian (parent/spouse/in-laws/ other) agree that you should attend? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total score

Aggregate adolescent in the community score

Overall score on Criterion 17 Category 1 2 3 4 Aggregate adolescent client score Aggregate adult client score Aggregate adult community member score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–9 0–10 0–1 0–21 0 to 100% Score

Absolute total score Relative score for Criterion 17

(

Total score 21

)

× 100

CRITERION 18. Policies are in place that define the required package of health information, counselling, diagnostic, treatment and care services and enable its provision. Health facility manager interview tool Number 18d Question Do you have at hand updated lists of: Services included in the package of information, counselling, treatment and care services that are to be provided to adolescents? Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total score

Direct observation (checklist) tool Number 15d Question Check the availability of the following lists. Services included in the package of information, counselling, treatment and care services to be provided to adolescents Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

24 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Health-care provider interview tool Number 6 Question Are you aware of services included in the package of information, counselling, treatment and care services to be provided to adolescents? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 18 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 18

(

Total score 3

)

× 100

CRITERION 19. Policies and procedures are in place that identify which health services are provided in the health facility and which in community settings such as schools. Health facility manager interview tool Number 7b Question Do you have any of the following guidelines/SOPs in your facility? SOPs for which services should be provided in the facility and which in the community 16c Does the facility have a documented plan: For provision of health services to adolescents in community settings? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 14a Question Check to see if there are the following SOPs/guidelines. SOPs for which services should be provided in the facility and which in the community Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 25

Health-care provider interview tool Number 8a Question Are you aware of the following SOPs/ guidelines? SOPs for which services should be provided in the facility and which in the community? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Overall score on Criterion 19 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–2 0–1 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 19

(

Total score 4

)

× 100

CRITERION 20. Policies and procedures are in place that describe the referral system to services within and outside the health sector, including provisions for transition care for adolescents with chronic conditions. Health facility manager interview tool Number 7c Question Do you have any of the following guidelines/SOPs in your facility? Referral guidelines 7d Do you have any of the following guidelines/SOPs in your facility? Policy/SOPs for a planned transition from paediatric to adult care 18b Do you have at hand updated lists of: Organizations from the health and other sectors, for example, social, recreational, legal sectors, that provide services to adolescents in the catchment area? Aggregate health facility manager score 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total score

26 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (checklist) tool Number 9d Question Check to see the following registers, tools and records. Referral register 14b Check to see if there are the following SOPs/guidelines. Referral guidelines 14c Check to see if there are the following SOPs/guidelines. Policy/SOPs for a planned transition from paediatric to adult care. 15b Check the availability of the following lists. Organizations from the health and other sectors (social, recreational, legal, etc.) providing services to adolescents in the catchment area Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 8b Question Are you aware of the following SOPs/ guidelines: Referral guidelines/SOPs? 8c Are you aware of the following SOPs/ guidelines: Policy/SOPs for a planned transition from paediatric to adult care? Aggregate health-care provider score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 20 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–3 0–4 0–2 0–9 0 to 100% Score

Absolute total score Relative score for Criterion 20

(

Total score 9

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 27

CRITERION 21. Health-care providers provide the required package of health information, counselling, diagnostic, treatment and care services in the facility and/or in community settings, in line with policies and procedures. Adolescent client exit interview tool Number 24 Question Have you ever received information, counselling or health services in the community setting (for example in school, clubs, community meetings, or any other?) Do you feel you could get a condom if you needed one? (Ask 15–19 year olds only.) Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the sum of responses coded “1”, “0” and “8” Total score

29d

1=Yes, 0=No, 8=Don’t know

Aggregate adolescent client score

Direct observation (client-provider interaction) tool Number 16a Question During the consultation did the service provider do the following: Provide sufficient time for counselling or consultation as required for the problem? Aggregate direct observation (client-provider interaction) score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of observations made Total score

Health-care provider interview tool Number 3a Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Normal growth and pubertal development Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

28 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 3b

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Pubertal delay

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

3c

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Precocious puberty

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3d

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Mental health and mental health problems

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 29

Number 3e

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Nutrition, including anaemia

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

3f

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Physical activity

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3g

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Adolescent-specific immunization

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

30 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 3h

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Menstrual hygiene and health

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

3i

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Family planning and contraception – oral contraceptive pills, IUDs, condoms, emergency contraceptive pills, implants, injectable contraceptives

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3j

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Safe abortion (where legal), and post-abortion care

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 31

Number 3k

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Antenatal care and emergency preparedness, delivery and postnatal care

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

3l

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Reproductive tract infections/sexually transmitted infections

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3m

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? HIV

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

32 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 3n

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Sexual violence

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

3o

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Family violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3p

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Bullying and school violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 33

Number 3q

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Substance use and substance use disorders

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories

3r

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Injuries

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3s

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Skin problems

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

34 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 3t

Question When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Chronic conditions and disabilities

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Score 1 if “Yes” is answered in each of the four categories – information, counselling and clinical services, referral Score 0.75 if “Yes” is answered in any three of the four categories – information, counselling and clinical services, referral Score 0.5 if “Yes” is answered in any two of the four categories – information, counselling and clinical services, referral Score 0.25 if “Yes” is answered in any one of the four categories – information, counselling and clinical services, referral Score 0 for “No” in all four categories Total number of responses coded as “1” divided by the total number of health-care providers interviewed

3u

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Endemic diseases

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

3v

When an adolescent client comes to your clinic, do you provide services for any of the following conditions or needs? Common conditions during adolescence (fatigue, abdominal pain, diarrhoea, headache)

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical services: 1=Yes, 0=No Referral: 1=Yes, 0=No

17b

Have you ever worked with: Organizations from health and other sectors (for example social, recreational, legal) to establish referral networks for adolescent clients?

1=Yes, 0=No

Aggregate health-care provider score

Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 35

Adolescent in the community interview tool Number 29 Question Have you ever received information, counselling or health services in the community setting, for example in schools, clubs, community meetings? Do you feel you could get a condom if you needed one? (Ask 15–19 year olds only.) Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

35d

1=Yes, 0=No, 8=Don’t know

Aggregate adolescent in the community score

Overall score on Criterion 21 Category 1 2 3 4 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–2 0–1 0–23 0–2 0–28 0 to 100% Score

Absolute total score Relative score for Criterion 21

(

Total score 28

)

× 100

CRITERION 22. Service providers refer adolescents to the appropriate service and level of care according to local policies and procedures, and follow the policies for transition care. Adolescent client exit interview tool Number 22b Question Did the provider give you a detailed referral note (stating the health condition, address of the referral, working hours and cost of services)? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

36 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (client-provider interaction) tool Number 17a Question Did the service provider refer the adolescent client to another health facility? Response 1=Yes, 0=No, 6=Not relevant Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of observations made. Total score

17b

When the service provider referred the adolescent client to another health facility, did he/she give a referral note mentioning the condition referred for, where to go (address), timing?

1=Yes, 0=No

Aggregate direct observation (client-provider interaction) score

Adolescent in the community interview tool Number 22b Question Did he/she give you a detailed referral note, stating the condition, address for referral, operating hours and cost of services? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 22 Category 1 2 3 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–2 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 22

(

Total score 4

)

× 100

CRITERION 23. The health facility provides a package of health services that fulfils the needs of all adolescents, in the facility and/or through referral linkages and outreach. Adolescent client exit interview tool Number 7 Question Today, did you get the services that you came for? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 37

Adolescent in the community interview tool Number 10 Question Did you receive the health-care services that you went for? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

22b

Did he/she give you a detailed referral note, stating the condition, address for referral, operating hours and cost of services? Have you ever received information, counselling or health services in the community setting, for example in schools, clubs, community meetings?

1=Yes, 0=No, 7=Can’t remember

29

1=Yes, 0=No, 7=Can’t remember

Aggregate adolescent in the community score

Overall score on Criterion 23 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–3 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 23

(

Total score 4

)

× 100

CRITERION 24. Health-care providers and support staff of the required profile are in place.

Health facility manager interview tool Number 5 Question Do you have job descriptions for each category of staff employed in your facility? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded “1” divided by the total number of facility managers interviewed Total number of responses coded “1” divided by the total number of facility managers interviewed Total number of responses coded “1” divided by the total number of facility managers interviewed

6a

Do the job descriptions of your staff include a focus on adolescent health care? Doctor

1=Yes, 0=No, 8=Don’t know

6b

Do the job descriptions of your staff include a focus on adolescent health care? Nurse

1=Yes, 0=No, 8=Don’t know

38 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 6c

Question Do the job descriptions of your staff include a focus on adolescent health care? Midwife

Response 1=Yes, 0=No, 8=Don’t know

Score Total number of responses coded “1” divided by the total number of facility managers interviewed Total number of responses coded “1” divided by the total number of facility managers interviewed Total number of responses coded “1” divided by the total number of facility managers interviewed Total number of responses coded “1” divided by the total number of facility managers interviewed Total score

6d

Do the job descriptions of your staff include a focus on adolescent health care? Outreach worker

1=Yes, 0=No, 8=Don’t know

6e

Do the job descriptions of your staff include a focus on adolescent health care? Counsellor

1=Yes, 0=No, 8=Don’t know

6f

Do the job descriptions of your staff include a focus on adolescent health care? Other (please specify) __________________

1=Yes, 0=No, 8=Don’t know

Aggregate health facility manager score

Direct observation (checklist) tool Number 16a Question Check if the job description of the following personnel is available AND has a focus on adolescent health care. Doctor 16b Check if the job description of the following personnel is available AND has a focus on adolescent health care. Nurse 16c Check if the job description of the following personnel is available AND has a focus on adolescent health care. Midwife 16d Check if the job description of the following personnel is available AND has a focus on adolescent health care. Outreach worker 16e Check if the job description of the following personnel is available AND has a focus on adolescent health care. Counsellor 16f Check if the job description of the following personnel is available AND has a focus on adolescent health care. Other (please specify) __________________ Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 39

Health-care provider interview tool Number 2 Question Has the facility manager discussed your job description and your roles and responsibilities with you? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 24 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–7 0–6 0–1 0–14 0 to 100% Score

Absolute total score Relative score for Criterion 24

(

Total score 14

)

× 100

CRITERION 25. Health-care providers have the technical competencies necessary to provide the required package of services. Health facility manager interview tool Number 3d Question Could you tell me which of these components were covered by the training in adolescent health? Clinical case management 4a Did you undergo any of the following trainings as facility manager? Orientation in adolescent health care Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 13d Question Check to see training records/reports for the following topics. Clinical case management of adolescent health conditions Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

40 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Health-care provider interview tool Number 4d Question Have you received the following training in adolescent health care: Clinical case management of adolescent patients? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 25 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–2 0–1 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 25

(

Total score 4

)

× 100

CRITERION 26. Health-care providers have been trained/sensitized on the importance of respecting the rights of adolescents to information, privacy, confidentiality, and of the health care that is provided in a respectful, non-judgemental and non-discriminatory manner. Health facility manager interview tool Number 3c Question Could you tell me which of these components were covered by the training in adolescent health? The policy on privacy and confidentiality 3e Could you tell me which of these components were covered by the training in adolescent health? Orientation on the importance of respecting the rights of adolescents to information and health care that is provided in a respectful, non-judgemental and non-discriminatory manner 4a Did you undergo any of the following trainings as facility manager? Orientation in adolescent health care Aggregate health facility manager score 1=Yes, 0=No 1=Yes, 0=No, 8=Don’t know Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 41

Direct observation (checklist) tool Number 13c Question Check to see training records/reports for the following topics. The policy on privacy and confidentiality 13e Check to see training records/reports for the following topics. Orientation on the importance of respecting the rights of adolescents to information and health care that is provided in a respectful, non-judgemental and non-discriminatory manner Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 4c Question Have you received the following training in adolescent health care: The policy on privacy and confidentiality? 4e Have you received the following training in adolescent health care: Orientation on the importance of respecting the rights of adolescents to information and health care that is provided in a respectful, non-judgemental and non-discriminatory manner? Aggregate health-care provider score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Support staff interview tool Number 5 Question Have you received any training in providing services to adolescents? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total number of responses coded as “1” divided by the total number of support staff interviewed Total number of responses coded as “1” divided by the total number of support staff interviewed

6b

Have you received any training/ orientation on the following topics: What are the special needs of adolescent clients?

1=Yes, 0=No

6c

Have you received any training/ orientation on the following topics: The importance of having the same friendly attitude towards all adolescents irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other?

1=Yes, 0=No

42 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 6d

Question Have you received any training/ orientation on the following topics: The importance of respecting the rights of adolescents to information, privacy, confidentiality, and respectful care?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of support staff interviewed

Aggregate support staff score

Total score

Overall score on Criterion 26 Category 1 2 3 4 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–3 0–2 0–2 0–4 0–11 0 to 100% Score

Absolute total score Relative score for Criterion 26

(

Total score 11

)

× 100

CRITERION 27. Providers’ obligations and adolescents’ rights are clearly displayed in the health facility.

Adolescent client exit interview tool Number 14a Question Have you seen a display with your rights? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

15

Have you seen a display which mentions that services will be provided to all adolescents without discrimination? Have you seen a display of the confidentiality policy?

1=Yes, 0=No

16

1=Yes, 0=No

Aggregate adolescent client score

Health facility manager interview tool Number 10a Question Do you have the following information items displayed in the facility? The rights of adolescents to information, non-judgemental attitude and respectful care Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 43

Number 10b

Question Do you have the following information items displayed in the facility? The policy commitment of the health facility to provide health services to all adolescents without discrimination, and to take remedial actions, if necessary

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

10c

Do you have the following information items displayed in the facility? The policy on confidentiality and privacy

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed

10d

Do you have the following information items displayed in the facility? The policy on free or affordable service provision for adolescents

1=Yes, 0=No

Aggregate health facility manager score

Total score

Direct observation (checklist) tool Number 12a Question Check if the following information items are displayed in the facility. The rights of adolescents to information, non-judgemental attitude and respectful care 12b Check if the following information items are displayed in the facility. The policy commitment of the health facility to provide health services to all adolescents without discrimination and to take remedial actions if necessary 12c Check if the following information items are displayed in the facility. The policy on confidentiality and privacy 12d Check if the following information items are displayed in the facility. The policy on free or affordable service provision for adolescents Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 2 for “Yes” or 0 for “No” 1=Yes, 0=No Score 2 for “Yes” or 0 for “No” 1=Yes, 0=No Score 2 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 2 for “Yes” or 0 for “No”

Health-care provider interview tool Number 24 Question How confident do you feel about your knowledge of how to provide care to adolescents? Response 1=Confident, 0=Somewhat/not confident Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

44 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Adolescent in the community interview tool Number 14b Question Did you see a display with your rights? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

15

Did you see a display of the confidentiality policy?

1=Yes, 0=No, 7=Can’t remember

Aggregate adolescent in the community score

Overall score on Criterion 27 Category 1 2 3 4 5 Aggregate adolescent client score Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–3 0–4 0–8 0–1 0–2 0–18 0 to 100% Score

Absolute total score Relative score for Criterion 27

(

Total score 18

)

× 100

CRITERION 28. Up-to-date decision support tools (guidelines, protocols, algorithms) that cover topics of clinical care in line with the package of services are in place. Health facility manager interview tool Number 7a Question Do you have any of the following guidelines/SOPs in your facility? Clinical case management guidelines or job aids/algorithms for adolescent health care Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 45

Direct observation (checklist) tool Number 6l Question Does the facility have the following equipment/material/supplies: BMI growth charts for adolescents 11a Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Normal growth and pubertal development Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

11b

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Pubertal delay

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11c

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Precocious puberty

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

46 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 11d

Question Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Mental health and mental health problems

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories

11e

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Nutrition (including anaemia)

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11f

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Physical activity

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11g

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Adolescent-specific immunization

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 47

Number 11h

Question Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Menstrual hygiene and health

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories

11i

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Family planning and contraception–oral contraceptive pills, IUDs, condoms, emergency contraceptive pills, implants, injectable contraceptives

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11j

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Safe abortion (where legal), and postabortion care

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11k

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Antenatal care and emergency preparedness, delivery and postnatal care

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

48 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 11l

Question Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Reproductive tract infections/sexually transmitted infections

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories

11m

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: HIV

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11n

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Sexual violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11o

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Family violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 49

Number 11p

Question Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Bullying and school violence

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories

11q

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Substance use and substance use disorders

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11r

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Injuries

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11s

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Skin problems

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

50 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 11t

Question Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Chronic conditions and disabilities

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical management Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical management Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical management Score 0 for “No” in all three categories Total score

11u

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Endemic diseases

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

11v

Check for guidelines and other decision support tools (e.g. job aids, algorithms) for information, counselling and clinical management in the following areas: Common conditions during adolescence (fatigue, abdominal pain, diarrhoea, headache)

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical management: 1=Yes, 0=No

Aggregate direct observation (checklist) score

Overall score on Criterion 28 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–1 0–23 0–24 0 to 100% Score

Absolute total score Relative score for Criterion 28

(

Total score 24

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 51

CRITERION 29. A system of supportive supervision is in place to improve health-care providers’ performance.

Health facility manager interview tool Number 7p Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on supportive supervision in adolescent health care 7q Do you have any of the following guidelines/SOPs in your facility? Tools for supportive supervision in adolescent health care Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 9j Question Check to see the following registers, tools and records. Tools for supportive supervision in adolescent health care 14o Check to see if there are the following guidelines/SOPs: Guidelines/SOPs on supportive supervision in adolescent health care 14p Check to see if there are the following guidelines/SOPs: Tools for supportive supervision in adolescent health care Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Support staff interview tool Number 7 Question Does your supervisor ever discuss your roles and responsibilities with you? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

8

Does your supervisor regularly provide supportive supervision to you for your work?

1=Yes, 0=No

Aggregate support staff score

52 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 29 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate support staff score Minimum – Maximum 0–2 0–3 0–2 0–7 0 to 100% Score

Absolute total score Relative score for Criterion 29

(

Total score 7

)

× 100

CRITERION 30. A system of continuous professional education that includes an adolescent health-care component is in place to ensure lifelong learning. Health facility manager interview tool Number 17a Question Do you have budget to ensure: Continuous professional education activities in adolescent health care for facility staff? 17b Do you have budget to ensure: Training of outreach workers in adolescent health care? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Health-care provider interview tool Number 5 Question Is there a system so that you can regularly (at least once every 5 years) attend continuous professional education training in adolescent health care? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 30 Category 1 2 Aggregate facility manager score Aggregate health-care provider score Minimum – Maximum 0–2 0–1 0–3 Score

Absolute total score Relative score for Criterion 30 0 to 100%

(

Total score 3

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 53

CRITERION 31. Health-care providers follow evidence-based guidelines and protocols in delivering care to adolescents.

Adolescent client exit interview tool Number 17c Question Today, during your consultation or counselling session: Did the service provider ask you questions about your home and your relationships with adults? 17d Today, during your consultation or counselling session: Did the service provider ask you questions about school? 17e Today, during your consultation or counselling session: Did the service provider ask you questions about your eating habits? 17f Today, during your consultation or counselling session: Did the service provider ask you questions about sports or other physical activity? 17g Today, during your consultation or counselling session: Did the service provider ask you questions about sexual relationships? 17h Today, during your consultation or counselling session: Did the service provider ask you questions about smoking, alcohol or other substances? 17i Today, during your consultation or counselling session: Did the service provider ask you questions about how happy you feel, or other questions about your mood or mental health? Aggregate adolescent client score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total score

54 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (client-provider interaction) tool Number 13a Question During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about home and relationships with adults? 13b During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about school? 13c During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about his/ her eating habits? 13d During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about sports or other physical activity? 13e During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about sexual relationships? 13f During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about smoking, alcohol or other substances? 13g During the consultation did the service provider take any psychosocial history, such as: Asked the adolescent questions about how happy he/she feels or other questions about his/her mood or mental health? Aggregate direct observation (client-provider interaction) score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made

Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 55

Health-care provider interview tool Number 7a Question Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Normal growth and pubertal development Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories

7b

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Pubertal delay

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7c

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Precocious puberty

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7d

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Mental health and mental health problems

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

56 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 7e

Question Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Nutrition (including anaemia)

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories

7f

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Physical activity

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7g

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Adolescent-specific immunization

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7h

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Menstrual hygiene and health

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 57

Number 7i

Question Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Family planning and contraception–oral contraceptive pills, IUDs, condoms, emergency contraceptive pills, implants, injectable contraceptives

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories

7j

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Safe abortion (where legal), and post-abortion care

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7k

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Antenatal care and emergency preparedness, delivery and postnatal care

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7l

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Reproductive tract infections/sexually transmitted infections

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

58 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 7m

Question Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: HIV

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories

7n

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Sexual violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7o

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Family violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7p

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Bullying and school violence

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 59

Number 7q

Question Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Substance use and substance use disorders

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories

7r

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Injuries

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7s

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Skin problems

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

7t

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Chronic conditions and disabilities

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

60 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 7u

Question Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Endemic diseases

Response Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

Score Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Score 1 if “Yes” is answered in each of the three categories – information, counselling and clinical care Score 0.66 if “Yes” is answered in any two of the three categories – information, counselling and clinical care Score 0.33 if “Yes” is answered in only one of the three categories – information, counselling and clinical care Score 0 for “No” in all three categories Total number of responses coded as “1” divided by the total number of health-care providers interviewed

7v

Do you use guidelines or decision support tools, for example, job aids or algorithms, for information, counselling and clinical management in the following areas: Common conditions during adolescence (fatigue, abdominal pain, diarrhoea, headache)

Information: 1=Yes, 0=No Counselling: 1=Yes, 0=No Clinical care: 1=Yes, 0=No

22a

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about home and relationships with adults?

1=Yes, 0=No

22b

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about school?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

22b

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about his/ her eating habits?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

22d

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about sports or other physical activity?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

22e

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about sexual relationships?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 61

Number 22f

Question During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about smoking, alcohol or other substances?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

22g

During a consultation with an adolescent client, do you routinely take a psychosocial history such as: Asking the adolescent questions about how happy he/she feels or other questions about his/her mood or mental health?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Aggregate health-care provider score

Total score

Overall score on Criterion 31 Category 1 2 3 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate health-care provider score Minimum – Maximum 0–7 0–7 0–29 0–43 0 to 100% Score

Absolute total score Relative score for Criterion 31

(

Total score 43

)

× 100

CRITERION 32. Health-care providers and support staff relate to adolescents in a friendly manner, and respect their rights to information, privacy, confidentiality, non-discrimination, non-judgemental attitude, and respectful care. Adolescent client exit interview tool Number 17j Question Today, during your consultation or counselling session: Did the service provider treat you in a friendly manner? 17k Today, during your consultation or counselling session: Was the service provider respectful of your needs? 18b Did you feel that support staff were friendly and treated you with respect? 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

62 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (client-provider interaction) tool Number 5a Question At the beginning of the consultation did the health-care provider: Seat the adolescent in the prime position that facilitated communication most easily? 5b At the beginning of the consultation did the health-care provider: Introduce himself/herself first to the adolescent? 5c At the beginning of the consultation did the health-care provider: Ask the adolescent what he/she would like to be called? 5d At the beginning of the consultation did the health-care provider: Ask the adolescent who he/she has brought with him/her to the consultation? 5e At the beginning of the consultation did the health-care provider: Show interest in the adolescent and spend some time getting to know him/her before focusing on the medical problems (problem-free talk)? 6b The provider asked questions first to the adolescent and then to the accompanying person(s). The provider asked the adolescent’s permission to ask the accompanying person(s) their opinions/observations. Did the service provider listen with attention to what the client had to say? 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No, 6=Not relevant 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the total number of observations made

Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made

6c

1=Yes, 0=No

8

1=Yes, 0=No

9

Did the service provider assure the client that no information will be disclosed to anyone (parents/other) without their permission? Did the service provider explain to the client the conditions when the provider might need to disclose information, such as in situations required by law, and if that is the case the client will be informed of the intention to disclose unless doing so would place them at further risk of harm? During the consultation did the service provider do the following: Ask the adolescent client’s permission before performing the examination/ procedure?

1=Yes, 0=No

10

1=Yes, 0=No

16l

1=Yes, 0=No, 6=Not relevant

Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 63

Number 16m

Question During the consultation did the service provider do the following: Explain the results of the physical examination to the client?

Response 1=Yes, 0=No, 6=Not relevant

Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

Aggregate direct observation (client-provider interaction) score

Total score

Health-care provider interview tool Number 21a Question When you see an adolescent client for services or counselling do you: Introduce yourself first to the adolescent? 21b When you see an adolescent client for services or counselling do you: Ask the adolescent what he/she likes to be called? 21c When you see an adolescent client for services or counselling do you: Ask the adolescent who he/she has brought with him/her to the consultation? 21e When you see an adolescent client for services or counselling do you: Ask the adolescent permission to ask the accompanying person(s) their opinions/ observations? Aggregate health-care provider score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Adolescent in the community interview tool Number 16 Question Was the service provider friendly to you? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

17a

Was the service provider respectful of what you needed?

1=Yes, 0=No, 7=Can’t remember

21b

Did you feel that the support staff was friendly and treated you with respect?

1=Yes, 0=No, 7=Can’t remember

Aggregate adolescent in the community score

64 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 32 Category 1 2 3 4 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–3 0–12 0–4 0–3 0–22 0 to 100% Score

Absolute total score Relative score for Criterion 32

(

Total score 22

)

× 100

CRITERION 33. Adolescents receive effective health services.

Effectiveness is measured against evidence-based standards of care (e.g. criterion-based audit) using a combination of methods, such as an audit of medical records and observation. Tools to measure the effectiveness of care of selected conditions are currently being developed and are not part of this guide. CRITERION 34. Adolescents receive services in a friendly, supportive, respectful, non-discriminatory and nonjudgemental manner, and know their rights in health care. Adolescent client exit interview tool Number 14b Question Can you tell me what your rights are? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

17j

Today, during your consultation or counselling session: Did the service provider treat you in a friendly manner?

1=Yes, 0=No

17k

Today, during your consultation or counselling session: Was the service provider respectful of your needs?

1=Yes, 0=No

18b

Did you feel that support staff were friendly and treated you with respect?

1=Yes, 0=No

Aggregate adolescent client score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 65

Adolescent in the community interview tool Number 14c Question Can you tell me what your rights are? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

16

Was the service provider friendly to you?

1=Yes, 0=No, 7=Can’t remember

17a

Was the service provider respectful of what you needed?

1=Yes, 0=No, 7=Can’t remember

21b

Did you feel that the support staff was friendly and treated you with respect?

1=Yes, 0=No, 7=Can’t remember

Aggregate adolescent in the community score

Overall score on Criterion 34 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–4 0–4 0–8 0 to 100% Score

Absolute total score Relative score for Criterion 34

(

Total score 8

)

× 100

CRITERION 35. Adolescents receive accurate, age-appropriate and clear information to facilitate informed choice.

Adolescent client exit interview tool Number 17o Question Today, during your consultation or counselling session: Do you feel that the health information provided during the consultation was clear and that you understood it well? Aggregate adolescent client score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total score

66 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Adolescent in the community interview tool Number 19 Question Did you feel the information provided during the consultation was clear and that you understood it well? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 35 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 35

(

Total score 2

)

× 100

CRITERION 36. A policy is in place, including assigned responsibilities across health-care providers and support staff, to ensure a welcoming and clean environment, minimize waiting times and ensure convenient operating hours and flexible appointment procedures. Health facility manager interview tool Number 7g Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs with staff responsibilities on making the health facility welcoming, convenient and clean 7h Do you have any of the following guidelines/SOPs in your facility? SOPs on how to minimize the waiting time for adolescent clients 7i Do you have any of the following guidelines/SOPs in your facility? SOPs on how to provide services to adolescents with, or without, an appointment 17e Do you have budget to ensure: Keeping the facility welcoming and clean? Aggregate health facility manager score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 67

Direct observation (checklist) tool Number 2a Question Does the waiting area: Have adequate and comfortable seating? 2c Does the waiting area: Have drinking water? 2d Does the waiting area: Seem welcoming overall? 2e Does the waiting area: Seem clean overall? 4 5a Are the surroundings of the facility clean? Does the facility furniture seem adequate? Regarding quantity? 5b Does the facility furniture seem adequate? Regarding the state of repair? 14f Check to see if there are the following guidelines/SOPs: Guidelines/SOPs including staff responsibilities for making the health facility welcoming, convenient, and clean 14g Check to see if there are the following guidelines/SOPs: SOPs on how to minimize waiting time 14h Check to see if there are the following guidelines/SOPs: SOPs on how to provide services to adolescents with or without an appointment Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 11a Question Have you ever discussed with your manager and your colleagues, and undertaken actions in order to: Make working hours convenient for adolescents? 11b Have you ever discussed with your manager and your colleagues, and undertaken actions in order to: Minimize waiting time? 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

68 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 11c

Question Have you ever discussed with your manager and your colleagues, and undertaken actions in order to: Provide services to adolescents with, or without an appointment?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

27

Do you have a clear designation of responsibilities within the facility to ensure a welcoming and clean environment?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Support staff interview tool Number 10a Question Have you ever participated in meetings where you discussed with your manager and colleagues: How to make operating hours convenient for adolescents? 10b Have you ever participated in meetings where you discussed with your manager and colleagues: How to minimize waiting time? 10c Have you ever participated in meetings where you discussed with your manager and colleagues: How to keep the facility welcoming and clean? 10d Have you ever participated in meetings where you discussed with your manager and colleagues: How to provide services to adolescents with or without an appointment? Aggregate support staff score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed

Total number of responses coded as “1” divided by the total number of support staff interviewed Total number of responses coded as “1” divided by the total number of support staff interviewed

Total number of responses coded as “1” divided by the total number of support staff interviewed

Total score

Overall score on Criterion 36 Category 1 2 3 4 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–4 0–10 0–4 0–4 0–22 0 to 100% Score

Absolute total score Relative score for Criterion 36

(

Total score 22

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 69

CRITERION 37. The facility has basic amenities (electricity, water, sanitation and waste disposal).

Health facility manager interview tool Number 15c Question Do you ensure that there are systems in place for: Basic amenities (electricity, water, sanitation and waste disposal)? 17d Do you have budget to ensure: Maintaining basic amenities of the facility in good condition? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 3a Question Check for basic amenities. Is there a functional toilet? 3b Check for basic amenities. Does the toilet have functioning hand hygiene facilities? 3c Check for basic amenities. Is the toilet clean? 3d Check for basic amenities. Does the toilet have a disposal bin? 3e Check for basic amenities. Does the facility have permanent electricity during working hours? 3f Check for basic amenities. Does the facility have general waste disposal? 3g Check for basic amenities. Does the facility have safe storage and disposal of clinical waste and potentially infectious waste that requires special disposal – such as disposable of equipment that may have come in contact with body fluids? 3h Check for basic amenities. Does the facility have safe storage and disposal of sharps? 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No”

Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No”

Score 1 for “Yes” or 0 for “No” Score 1 for “Yes” or 0 for “No”

Score 1 for “Yes” or 0 for “No”

70 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 3i

Question Check for basic amenities. Does the facility have adequate hand hygiene facilities that are located in or adjacent to the office/examination room?

Response 1=Yes, 0=No

Score Score 1 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

Overall score on Criterion 37 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–2 0–9 0–11 0 to 100% Score

Absolute total score Relative score for Criterion 37

(

Total score 11

)

× 100

CRITERION 38. Policies and procedures to protect the privacy and confidentiality of adolescents are in place. Both health-care providers and support staff know them as well as their own roles and responsibilities. Health facility manager interview tool Number 7e Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on protecting the privacy and confidentiality of adolescents 11a In your facility, are the following procedures established to ensure privacy, confidentiality and the security of medical information? Information on the identity of the adolescent and the presenting issue are gathered in confidence during the registration. 11b In your facility, are the following procedures established to ensure privacy, confidentiality and the security of medical information? Staff do not disclose any information given to or received from an adolescent to third parties, such as family members, school teachers or employers, without the adolescent’s consent. 1=Yes, 0=No Total number of responses coded as “1” divided by the total number of facility managers interviewed 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 71

Number 11c

Question In your facility, are the following procedures established to ensure privacy, confidentiality and the security of medical information? Case records are kept in a secure place, accessible only to authorized personnel.

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

11d

In your facility, are the following procedures established to ensure privacy, confidentiality and the security of medical information? Measures are implemented to prevent unauthorized access to electronically stored information.

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of facility managers interviewed

11e

In your facility, are the following procedures established to ensure privacy, confidentiality and the security of medical information? To maintain privacy during the consultation, there are curtains in windows and doors and a screen separating the consultation area from the examination area.

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of facility managers interviewed

Aggregate health facility manager score

Total score

Direct observation (checklist) tool Number 8a Question Check for visual and auditory privacy features. There are curtains on the doors and windows. 8b Check for visual and auditory privacy features. Communication between reception staff and visitors is private and cannot be overheard, including from the waiting room. 8c Check for visual and auditory privacy features. In the offices/examining rooms, there is a screen to separate the examination area from the consultation area. 8d Check for visual and auditory privacy features. No one can see or hear an adolescent client from the outside during the consultation or counselling. 10b Check for confidentiality procedures and their application in practice. Adolescent clients are offered anonymous registration if they wish. 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

72 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 10c

Question Check for confidentiality procedures and their application in practice. The registration register has the name and code, but the service register has only the code (if anonymous registration is asked for).

Response 1=Yes, 0=No

Score Score 1 for “Yes” or 0 for “No”

10d

Check for confidentiality procedures and their application in practice. The information in laboratory registers (if applicable) is registered using codes.

1=Yes, 0=No

Score 1 for “Yes” or 0 for “No”

10e

Check for confidentiality procedures and their application in practice. Case records are kept in a secure place, accessible only to authorized personnel.

1=Yes, 0=No

Score 1 for “Yes” or 0 for “No”

10f

Check for confidentiality procedures and their application in practice. The registers are kept under lock and key outside operating hours.

1=Yes, 0=No

Score 1 for “Yes” or 0 for “No”

10g

Check for confidentiality procedures and their application in practice. For electronically stored information, measures are applied to prevent unauthorized access.

1=Yes, 0=No

Score 1 for “Yes” or 0 for “No”

14d

Check to see if there are the following guidelines/SOPs: Guidelines/SOPs on protecting the privacy and confidentiality of adolescents

1=Yes, 0=No

Score 1 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

Health-care provider interview tool Number 8g Question Are you aware of the following SOPs/ guidelines: Guidelines/SOP on measures to protect the privacy and confidentiality of adolescents? 9 Can you please name any measures to protect the privacy and confidentiality of adolescents? 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 73

Support staff interview tool Number 17 Question Do you think it is OK to tell the parents or teachers of an adolescent client about the problem he/she came to the facility with, without the adolescent knowing? Response 0=Yes, 1=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

Aggregate support staff score

Overall score on Criterion 38 Category 1 2 3 4 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–6 0–11 0–2 0–1 0–20 0 to 100% Score

Absolute total score Relative score for Criterion 38

(

Total score 20

)

× 100

CRITERION 39. A system of procurement and stock management of the medicines and supplies necessary to deliver the required package of services is in place. Health facility manager interview tool Number 15a Question Do you ensure that there are systems in place for: Procurement and stock management of the medicines and supplies necessary to deliver the required package of services to adolescents? 18c Do you have at hand updated lists of: Medicine, supplies and necessary equipment? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 9c Question Check to see the following registers, tools and records. Stock of medicines and supplies register Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

74 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 15c

Question Check the availability of the following lists. Medicines, supplies and necessary equipment

Response 1=Yes, 0=No

Score Score 1 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

Overall score on Criterion 39 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–2 0–2 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 39

(

Total score 4

)

× 100

CRITERION 40. A system of procurement, inventory, maintenance and safe use of the equipment necessary to deliver the required package of services is in place. Health facility manager interview tool Number 15b Question Do you ensure that there are systems in place for: Procurement, inventory, maintenance and safe use of the equipment necessary to deliver the required package of services to adolescents? 18c Do you have at hand updated lists of: Medicine, supplies and necessary equipment? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 15c Question Check the availability of the following lists. Medicines, supplies and necessary equipment Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 75

Overall score on Criterion 40 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–2 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 40

(

Total score 3

)

× 100

CRITERION 41. Health-care providers offer consultations during hours that are convenient to adolescents in local communities, with or without an appointment. Health-care provider interview tool Number 13 Question Do you think the working hours in this facility are convenient for adolescents? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

14

Can adolescents have a consultation without an appointment?

1=Yes, 0=No, 8=Don’t know

Aggregate health-care provider score

Support staff interview tool Number 13 Question Can adolescents have a consultation without an appointment? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

Aggregate support staff score

Overall score on Criterion 41 Category 1 2 Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–2 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 41

(

Total score 3

)

× 100

76 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 42. Health-care providers and support staff follow policies and procedures to protect the privacy and confidentiality of adolescents. Adolescent client exit interview tool Number 4 Question If you came accompanied by another person, did you have some time alone with the health-care provider? Today, when you visited the facility, did you find that it has: Curtains in doors and on windows so that nobody can see you during the examination? 17m Today, during your consultation or counselling session: Did the service provider assure you at the beginning of the consultation that your information will not be shared with anyone without your consent? Aggregate adolescent client score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

12c

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total score

Direct observation (checklist) tool Number 10a Question Check for confidentiality procedures and their application in practice. Information on the identity of the adolescent and the presenting issue are gathered in confidence during registration. 10b Check for confidentiality procedures and their application in practice. Adolescent clients are offered anonymous registration if they wish. 10c Check for confidentiality procedures and their application in practice. The registration register has the name and code, but the service register has only the code (if anonymous registration is asked for). 10d Check for confidentiality procedures and their application in practice. The information in laboratory registers (if applicable) is registered using codes. 10e Check for confidentiality procedures and their application in practice. Case records are kept in a secure place, accessible only to authorized personnel. 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 77

Number 10f

Question Check for confidentiality procedures and their application in practice. The registers are kept under lock and key outside operating hours.

Response 1=Yes, 0=No

Score Score 1 for “Yes” or 0 for “No”

10g

Check for confidentiality procedures and their application in practice. For electronically stored information, measures are applied to prevent unauthorized access.

1=Yes, 0=No

Score 1 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

Direct observation (client-provider interaction) tool Number 2 Question Do you think that during the consultation the provider and the client could be seen from the outside? Is it possible to overhear the conversation between service provider and the client from the outside? Apart from the service providers that were concerned with the consultation (doctor or/ and nurse), was anyone else present in the room at the time of consultation? (This includes health-care providers that are not concerned directly with this particular consultation.) The provider explained to the adolescent that they routinely spend some time alone with the adolescent towards the end of the consultation. Did anyone else enter the room during the consultation? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made

3

1=Yes, 0=No

4

1=Yes, 0=No

6a

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made

7

0=Yes, 1=No

9

Did the service provider assure the client that no information will be disclosed to anyone (parents/other) without their permission? Did the service provider explain to the client the conditions when the provider might need to disclose information, such as in situations required by law, and if that is the case the client will be informed of the intention to disclose unless doing so would place them at further risk of harm? If the adolescent was accompanied by someone else (for example, parent/guardian, sister) did the provider spend some time alone with the adolescent towards the end of the consultation?

1=Yes, 0=No

10

1=Yes, 0=No

15

1=Yes, 0=No, 6=Not relevant

Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate direct observation (client-provider interaction) score

78 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Health-care provider interview tool Number 21d Question When you see an adolescent client for services or counselling do you: Explain to adolescents that are accompanied that you routinely spend some time alone with the adolescent towards the end of the consultation? 21g When you see an adolescent client for services or counselling do you: Ensure that no one can see or hear the adolescent client from outside during the consultation or counselling? 21h When you see an adolescent client for services or counselling do you: Ensure that there is a screen between the consultation and examination area? 21i When you see an adolescent client for services or counselling do you: Assure the adolescent client that no information will be disclosed to any one (parents/other) without his/her permission? 21j When you see an adolescent client for services or counselling do you: Explain to the adolescent client the conditions when you might need to disclose information, such as in situations required by law, and if that is the case you will inform him/her of the intention to disclose unless doing so would place them at further risk of harm? 21k When you see an adolescent client for services or counselling do you: Keep all records/lab test reports under lock and key or password protected if in the computer? Aggregate health-care provider score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Support staff interview tool Number 16 Question During the registration of adolescents/ youth, can anyone else overhear your conversation? Response 0=Yes, 1=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

Aggregate support staff score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 79

Adult client exit interview tool Number 7c Question Did the health service provider get permission from that adolescent before disclosing this information to you? Response 1=Yes, 0=No, 8=Don’t know, 6=Not relevant (no adolescent in the family) 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

8b

Did the provider spent time alone with the adolescent towards the end of the consultation?

Aggregate adult client score

Adolescent in the community interview tool Number 6b Question If you were accompanied by another person, did you have some time alone with the health-care provider? The last time you visited the nearby facility, did you find it had: Curtains in doors and on windows so that nobody could see you during the examinations? 17b Did anyone else enter the room during your consultation? 1=Yes, 0=No, 7=Can’t remember Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

12c

1=Yes, 0=No, 7=Can’t remember

Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

18a

At the beginning of the consultation, did the service provider assure you that your information would not be shared with anyone without your consent?

1=Yes, 0=No, 7=Can’t remember

Aggregate adolescent in the community score

80 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 42 Category 1 2 3 4 5 6 7 Aggregate adolescent client score Aggregate direct observation (checklist) score Aggregate direct observation (client-provider interaction) score Aggregate health-care provider score Aggregate support staff score Aggregate adult client score Aggregate adolescent in the community score Minimum – Maximum 0–3 0–7 0–8 0–6 0–1 0–2 0–4 0–31 0 to 100% Score

Absolute total score Relative score for Criterion 42

(

Total score 31

)

× 100

CRITERION 43. Medicines and supplies are in adequate quantities without shortages (stock-outs), and are equitably used. Adolescent client exit interview tool Number 19 Question Today, did you not get the services you wanted because of a lack of medicines or other materials? Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Direct observation (checklist) tool Number 6p Question Does the facility have the following equipment/material/supplies: Latex gloves 6q Does the facility have the following equipment/material/supplies: Single-use standard disposable or autodisposable syringes 6r Does the facility have the following equipment/material/supplies: Soap or alcohol-based hand rub for hand hygiene 1=Yes, 0=No Score 0.75 for “Yes” or 0 for “No” 1=Yes, 0=No Score 0.75 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 0.75 for “Yes” or 0 for “No”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 81

Number 7a

Question Check the minimum levels of stock for the following medicines and supplies in the facility. Condoms

Response 1=Yes, 0=No

Score Score 0.75 for “Yes” or 0 for “No”

7b

Check the minimum levels of stock for the following medicines and supplies in the facility. Oral contraceptive pills

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7c

Check the minimum levels of stock for the following medicines and supplies in the facility. Emergency contraceptive pills

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7d

Check the minimum levels of stock for the following medicines and supplies in the facility. Injectable contraceptives

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7e

Check the minimum levels of stock for the following medicines and supplies in the facility. Contraceptive implants

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7f

Check the minimum levels of stock for the following medicines and supplies in the facility. Intravenous fluids

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7g

Check the minimum levels of stock for the following medicines and supplies in the facility. Paracetamol

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7h

Check the minimum levels of stock for the following medicines and supplies in the facility. Amoxicillin

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7i

Check the minimum levels of stock for the following medicines and supplies in the facility. Atenolol

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7j

Check the minimum levels of stock for the following medicines and supplies in the facility. Ceftriaxone

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7k

Check the minimum levels of stock for the following medicines and supplies in the facility. Ciprofloxacin

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

82 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 7l

Question Check the minimum levels of stock for the following medicines and supplies in the facility. Cotrimoxazole suspension

Response 1=Yes, 0=No

Score Score 0.75 for “Yes” or 0 for “No”

7m

Check the minimum levels of stock for the following medicines and supplies in the facility. Diclofenac

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7n

Check the minimum levels of stock for the following medicines and supplies in the facility. Glibenclamide

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7o

Check the minimum levels of stock for the following medicines and supplies in the facility. Omeprazole

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7p

Check the minimum levels of stock for the following medicines and supplies in the facility. Salbutamol

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7q

Check the minimum levels of stock for the following medicines and supplies in the facility. Diazepam

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7r

Check the minimum levels of stock for the following medicines and supplies in the facility. Magnesium sulfate

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

7s

Check the minimum levels of stock for the following medicines and supplies in the facility. Vaccines

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

Health-care provider interview tool Number 28a Question Has any adolescent been denied services within last 12 months because of: Recent stock-outs? Aggregate health-care provider score Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 83

Adolescent in the community interview tool Number 24 Question Were you ever refused health-care services in the nearby facility because of lack of medicines or other materials? Response 0=Yes, 1=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 43 Category 1 2 3 4 Aggregate adolescent client score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–22 0–1 0–1 0–25 0 to 100% Score

Absolute total score Relative score for Criterion 43

(

Total score 25

)

× 100

CRITERION 44. The equipment necessary to provide the required package of services to adolescents is available, functioning and equitably used. Adolescent client exit interview tool Number 20 Question Today, did you not get the services you wanted because of a lack of equipment, or because the equipment was not functioning? Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Direct observation (checklist) tool Number 6a Question Does the facility have the following equipment/material/supplies: Blood pressure measurement machine 6b Does the facility have the following equipment/material/supplies: Binaural adult stethoscope 6c Does the facility have the following equipment/material/supplies: Monaural fetal stethoscope 1=Yes, 0=No Score 0.75 for “Yes” or 0 for “No” 1=Yes, 0=No Score 0.75 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 0.75 for “Yes” or 0 for “No”

84 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 6d

Question Does the facility have the following equipment/material/supplies: Pregnancy test strips

Response 1=Yes, 0=No

Score Score 0.75 for “Yes” or 0 for “No”

6e

Does the facility have the following equipment/material/supplies: Clinical thermometer

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6f

Does the facility have the following equipment/material/supplies: Adult weighing scales

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6g

Does the facility have the following equipment/material/supplies: Measuring tape

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6h

Does the facility have the following equipment/material/supplies: Light source, for example a torch

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6i

Does the facility have the following equipment/material/supplies: Refrigerator

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6j

Does the facility have the following equipment/material/supplies: Haemoglobinometer

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6k

Does the facility have the following equipment/material/supplies: Test strips for urine, 10 parameter

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6m

Does the facility have the following equipment/material/supplies: Height meter

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6n

Does the facility have the following equipment/material/supplies: Ophtalmoscope set

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6o

Does the facility have the following equipment/material/supplies: Otoscope set

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6s

Does the facility have the following equipment/material/supplies: Communication equipment (phone or short-wave radio)

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

6t

Does the facility have the following equipment/material/supplies: Computer with email/internet access

1=Yes, 0=No

Score 0.75 for “Yes” or 0 for “No”

Aggregate direct observation (checklist) score

Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 85

Health-care provider interview tool Number 28b Question Has any adolescent been denied services within last 12 months because of: Malfunctioning/unavailable equipment? Aggregate health-care provider score Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Adolescent in the community interview tool Number 25 Question Were you ever refused health-care services in the nearby facility because lack of equipment, or because the equipment was not functioning? Response 0=Yes, 1=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 44 Category 1 2 3 4 Aggregate adolescent client score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–12 0–1 0–1 0–15 0 to 100% Score

Absolute total score Relative score for Criterion 44

(

Total score 15

)

× 100

CRITERION 45. The health facility has convenient operating hours, appointment procedures and waiting times kept to a minimum. Adolescent client exit interview tool Number 12a Question Today, when you visited the facility, did you find that it has: Working hours that are convenient for you? 12b Today, when you visited the facility, did you find that it has: A reasonably short waiting time? (Ask how long the client waited.) Aggregate adolescent client score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

86 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Adolescent in the community interview tool Number 12a Question The last time you visited the nearby facility, did you find it had: Working hours that were convenient for you? 12b The last time you visited the nearby facility, did you find it had: A reasonably short waiting time? (Ask how long the client waited.) Aggregate adolescent in the community score 1=Yes, 0=No, 7=Can’t remember Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Overall score on Criterion 45 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–2 0–2 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 45

(

Total score 4

)

× 100

CRITERION 46. The health facility has a welcoming and clean environment.

Adolescent client exit interview tool Number 12d Question Today, when you visited the facility, did you find that it has: Comfortable seating in the waiting area? 12e Today, when you visited the facility, did you find that it has: Drinking water available? 13a Were the following sufficiently clean: Surroundings? 13b Were the following sufficiently clean: Consultation areas? 13c Were the following sufficiently clean: Toilets, which were functional? Aggregate adolescent client score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 87

Adolescent in the community interview tool Number 12d Question The last time you visited the nearby facility, did you find it had: Comfortable seating in the waiting area? 12e The last time you visited the nearby facility, did you find it had: Drinking water available? 13a Were the following sufficiently clean: The surroundings? 13b Were the following sufficiently clean: The consultation areas? 13c Were the following sufficiently clean: Toilets, which were functional? Aggregate adolescent in the community score 1=Yes, 0=No, 7=Can’t remember 1=Yes, 0=No, 7=Can’t remember Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

1=Yes, 0=No, 7=Can’t remember

1=Yes, 0=No, 7=Can’t remember

Overall score on Criterion 46 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–5 0–5 0–10 0 to 100% Score

Absolute total score Relative score for Criterion 46

(

Total score 10

)

× 100

CRITERION 47. Adolescents receive private and confidential health care at all times during the consultation process.

Adolescent client exit interview tool Number 4 Question If you came accompanied by another person, did you have some time alone with the health-care provider? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

88 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 12c

Question Today, when you visited the facility, did you find that it has: Curtains in doors and on windows so that nobody can see you during the examination?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

17l

Today, during your consultation or counselling session: Did anyone else enter the room during your consultation?

0=Yes, 1=No

Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

17n

Today, during your consultation or counselling session: Do you feel confident that the information you shared with service provider today will not be disclosed to anyone else without your consent?

1=Yes, 0=No

Aggregate adolescent client score

Total score

Adolescent in the community interview tool Number 6b Question If you were accompanied by another person, did you have some time alone with the health-care provider? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

12c

The last time you visited the nearby facility, did you find it had: Curtains in doors and on windows so that nobody could see you during the examinations?

1=Yes, 0=No, 7=Can’t remember

18b

Did you feel confident that the information you shared with the service provider would not be shared with anyone else without your consent?

1=Yes, 0=No, 7=Can’t remember

Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 47 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–4 0–3 0–7 0 to 100% Score

Absolute total score Relative score for Criterion 47

(

Total score 7

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 89

CRITERION 48. The facility has the equipment, medicines, supplies and technology needed to ensure effective service provision to adolescents. Adolescent client exit interview tool Number 19 Question Today, did you not get the services you wanted because of a lack of medicines or other materials? Today, did you not get the services you wanted because of a lack of equipment, or because the equipment was not functioning? Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

20

0=Yes, 1=No

Aggregate adolescent client score

Adolescent in the community interview tool Number 24 Question Were you ever refused health-care services in the nearby facility because of lack of medicines or other materials? Were you ever refused health-care services in the nearby facility because lack of equipment, or because the equipment was not functioning? Response 0=Yes, 1=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

25

0=Yes, 1=No, 8=Don’t know

Aggregate adolescent in the community score

Overall score on Criterion 48 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–2 0–2 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 48

(

Total score 4

)

× 100

90 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 49. Policies and procedures are in place stating the obligation of facility staff to provide services to all adolescents irrespective of their ability to pay, age, sex, marital status, schooling, race/ethnicity, sexual orientation or other characteristics. Health facility manager interview tool Number 7k Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on how to provide equitable services to all adolescents irrespective of their ability to pay, age, sex, marital status and other characteristics 10b Do you have the following information items displayed in the facility? The policy commitment of the health facility to provide health services to all adolescents without discrimination and to take remedial actions, if necessary Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total number of responses coded as “1” divided by the total number of facility managers interviewed

Total score

Direct observation (checklist) tool Number 14j Question Check to see if there are the following guidelines/SOPs: Guidelines/SOPs on equitable service provision to all adolescents irrespective of their ability to pay, age, sex, marital status or other characteristics Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 8e Question Are you aware of the following SOPs/ guidelines: Guidelines/SOPs on providing services to all adolescents irrespective of their ability to pay, age, sex, marital status or other characteristics? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 91

Overall score on Criterion 49 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–2 0–1 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 49

(

Total score 4

)

× 100

CRITERION 50. Policies and procedures are in place for services that are free at the point of use, or affordable.

Health facility manager interview tool Number 7j Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on how to provide free, or affordable, services to adolescents 10d Do you have the following information items displayed in the facility? The policy on free or affordable service provision for adolescents Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 12d Question Check if the following information items are displayed in the facility. The policy on free or affordable service provision for adolescents 13f Check to see training records/reports for the following topics. Policies and procedures to ensure free or affordable service provision 14i Check to see if there are the following guidelines/SOPs. Guidelines/SOPs on applying policies for free, or affordable, service provision to adolescents Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

92 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Health-care provider interview tool Number 8f Question Are you aware of the following SOPs/ guidelines: Guidelines/SOPs on providing free, or affordable, services to adolescents? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 50 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–2 0–3 0–1 0–6 0 to 100% Score

Absolute total score Relative score for Criterion 50

(

Total score 6

)

× 100

CRITERION 51. Health-care providers and support staff are aware of the above policies and procedures, and know how to implement them. Health facility manager interview tool Number 3f Question Could you tell me which of these components were covered by the training in adolescent health? Policies and procedures to ensure free or affordable service provision Aggregate health facility manager score Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

Total score

Health-care provider interview tool Number 4f Question Have you received the following training in adolescent health care: Policies and procedures to ensure free or affordable service provision? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 93

Overall score on Criterion 51 Category 1 2 Aggregate facility manager score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 51

(

Total score 2

)

× 100

CRITERION 52. The policy commitment of the health facility to provide health services to all adolescents without discrimination, and to take remedial actions when necessary, is displayed prominently in the health facility. Adolescent client exit interview tool Number 15 Question Have you seen a display which mentions that services will be provided to all adolescents without discrimination? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Direct observation (checklist) tool Number 12b Question Check if the following information items are displayed in the facility. The policy commitment of the health facility to provide health services to all adolescents without discrimination and to take remedial actions if necessary Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Adolescent in the community interview tool Number 14a Question Did you see a display which mentions that services will be provided to all adolescents without discrimination? Response 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

94 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 52 Category 1 2 3 Aggregate adolescent client score Aggregate direct observation (checklist) score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 52

(

Total score 3

)

× 100

CRITERION 53. Health-care providers know who are the vulnerable group(s) of adolescents in their community(ies).

Health-care provider interview tool Number 10 Question Do you know any groups of adolescents in your community(ies)that are vulnerable regarding health issues? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 53 Category 1 Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0 to 100% Score

Absolute total score Relative score for Criterion 53

(

Total score 1

)

× 100

CRITERION 54. Health-care providers and support staff demonstrate the same friendly, non-judgemental and respectful attitude to all adolescents, regardless of age, sex, marital status, sexual orientation, cultural background, ethnic origin, disability or any other reason.

This criterion is measured by comparing scores of criteria 32 and 34 among various socio-economic groups (e.g. by comparing scores in boys and girls, married and unmarried, etc.). If health-care providers and support staff demonstrate the same attitude then no significant differences in scores for aforementioned criteria should be detected during comparisons by socio-economic groups.

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 95

CRITERION 55. Health-care providers provide services to all adolescents without discrimination, in line with policies and procedures. Health-care provider interview tool Number 23a Question Would you provide the following services to all adolescents regardless of sex, age, marital status or ability to pay? Hormonal contraceptives 23b Would you provide the following services to all adolescents regardless of sex, age, marital status or ability to pay? Condoms 23c Would you provide the following services to all adolescents regardless of sex, age, marital status or ability to pay? STI treatment 23d Would you provide the following services to all adolescents regardless of sex, age, marital status or ability to pay? HIV testing and counselling 23e Would you provide the following services to all adolescents regardless of sex, age, marital status or ability to pay? Medical termination of pregnancy/abortion (where legal) Aggregate health-care provider score 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Overall score on Criterion 55 Category 1 Aggregate health-care provider score Minimum – Maximum 0–5 0–5 0 to 100% Score

Absolute total score Relative score for Criterion 55

(

Total score 5

)

× 100

96 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 56. The health facility involves vulnerable group(s) of adolescents in the planning, monitoring and evaluation of health services, as well as in certain aspects of health-service provision. Health-care provider interview tool Number 16c Question Have you ever involved any of the following groups in these activities: Vulnerable groups of adolescents in the planning, monitoring and evaluation of health services and service provision? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Overall score on Criterion 56 Category 1 Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0 to 100% Score

Absolute total score Relative score for Criterion 56

(

Total score 1

)

× 100

CRITERION 57. All adolescents – irrespective of their ability to pay, age, sex, marital status, education, ethnic origin, sexual orientation or other characteristics – report similar experiences of care. Adolescent client exit interview tool Number 21a Question Today, were you denied necessary services at this health facility? Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Direct observation (client-provider interaction) tool Number 11 Question Did the service provider deny any services to this adolescent/young client? Response 0=Yes, 1=No Score Total number of responses coded as “1” divided by the total number of observations made Total score

Aggregate direct observation (client-provider interaction) score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 97

Adolescent in the community interview tool Number 23a Question Were you ever denied necessary services at the nearby facility? Response 0=Yes, 1=No, 6=Not relevant Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate adolescent in the community score

Overall score on Criterion 57 Category 1 2 3 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 57

(

Total score 3

)

× 100

In addition, criterion 57 could be measured by comparing scores of criteria 23, 32, 34, 35, 47 and 55 among various socio-economic groups (e.g. by comparing scores in boys and girls, married and unmarried, etc.). If all adolescents have a similar experience of care, then no significant differences in scores for the aforementioned criteria should be detected during comparisons by socio-economic groups. CRITERION 58. Vulnerable group(s) of adolescents are involved in the planning, monitoring and evaluation of health services, as well as in certain aspects of health-service provision.

Criterion 58 is measured by analysing criteria 77 and 79 separately for vulnerable adolescents. CRITERION 59. A system is in place to collect data on service utilization that is disaggregated by age, sex and other socio-demographic characteristics as relevant. Health facility manager interview tool Number 12 Question Is there a system in place in the facility to collect data on cause-specific service utilization by adolescents that is disaggregated by age and sex? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Aggregate health facility manager score

98 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (checklist) tool Number 9a Question Check to see the following registers, tools and records. The register on service utilization has data disaggregated by age and sex so that cause-specific service utilization by adolescent boys and girls can be extracted. 9b Check to see the following registers, tools and records. The reporting forms have a format that allows the presentation of data disaggregated by age and sex. Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 29a Question Is it possible to extract from your registers data on cause-specific service utilization by adolescents, along with the sex of adolescents? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Support staff interview tool Number 14 Question Is there a separate register for the registration of adolescents/youth? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

15

Are there separate columns for registering adolescents/youth in the common register?

1=Yes, 0=No, 8=Don’t know

Aggregate support staff score

Overall score on Criterion 59 Category 1 2 3 4 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–1 0–2 0–1 0–2 0–6 0 to 100% Score

Absolute total score Relative score for Criterion 59

(

Total score 6

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 99

CRITERION 60. Health-care providers are trained to collect and analyse data to inform quality improvement initiatives.

Health facility manager interview tool Number 3g Question Could you tell me which of these components were covered by the training in adolescent health? Data collection, analysis and use for quality improvement 4b Did you undergo any of the following trainings as facility manager? Training in quality improvement for adolescent health care Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 13g Question Check to see training records/reports for the following topics. Data collection, analysis and use for quality improvement in adolescent health care Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 4g Question Have you received the following training in adolescent health care: Data collection, analysis and use for quality improvement? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 60 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–2 0–1 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 60

(

Total score 4

)

× 100

100 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 61. Tools and mechanisms for self-monitoring of the quality of health services for adolescents are in place. Health facility manager interview tool Number 7l Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on self-monitoring of the quality of care provided to adolescents Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 9i Question Check to see the following registers, tools and records. Tools for facility self-assessment of the quality of adolescent health care 14k Check to see if there are the following guidelines/SOPs: Guidelines/SOPs for self-monitoring of the quality of care provided to adolescents Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 30a Question Are you aware of any tools for self-monitoring of the quality of care in the facility? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 61 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–2 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 61

(

Total score 4

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 101

CRITERION 62. Mechanisms are in place to link supportive supervision to priorities for improvement as identified during the monitoring of the implementation of standards. Health facility manager interview tool Number 4c Question Did you undergo any of the following trainings as facility manager? Training in supportive supervision for adolescent health care 9e Does your facility regularly conduct self-assessments: To inform priorities for supportive supervision? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Overall score on Criterion 62 Category 1 Aggregate facility manager score Minimum – Maximum 0–2 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 62

(

Total score 2

)

× 100

CRITERION 63. Mechanisms are in place for reward and recognition of highly performing health-care providers and support staff. Health facility manager interview tool Number 7o Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on how to reward and recognize highly performing staff 17f Do you have budget to ensure: Rewarding highly performing staff? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

102 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (checklist) tool Number 14n Question Check to see if there are the following guidelines/SOPs: Guidelines/SOPs on the reward for and recognition of highly performing staff Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Overall score on Criterion 63 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–2 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 63

(

Total score 3

)

× 100

CRITERION 64. The health facility collects data on service utilization disaggregated by age and sex, and conducts regular self-assessments of quality of care. Health facility manager interview tool Number 9c Question Does your facility regularly conduct self-assessments: To assess the quality of health-care services? Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Direct observation (checklist) tool Number 9k Question Check to see the following registers, tools and records. Records/reports on accomplished selfassessments of the quality of adolescent health care Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 103

Health-care provider interview tool Number 12 Question Did you ever participate in a facility self–assessment of the quality of care provided to adolescents? Do you use these tools for self-monitoring of quality for adolescent health services? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

30b

1=Yes, 0=No

Aggregate health-care provider score

Support staff interview tool Number 11a Question Did you ever participate in a facility selfassessment of the quality of care provided to adolescents? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

Aggregate support staff score

Overall score on Criterion 64 Category 1 2 3 4 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–1 0–1 0–2 0–1 0–5 0 to 100% Score

Absolute total score Relative score for Criterion 64

(

Total score 5

)

× 100

CRITERION 65. Health-care providers and support staff use data on service utilization and quality of care for action planning and implementation of quality improvement initiatives. Health facility manager interview tool Number 9d Question Does your facility regularly conduct self-assessments: To establish action plans for improvements? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

104 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 16d

Question Does the facility have a documented plan: For actions to improve the quality of care in the facility based on the results of the last self-assessment?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Aggregate health facility manager score

Health-care provider interview tool Number 31a Question Did you ever participate in facility meetings to analyse the results of the self-assessments and to plan actions for improvement of adolescent health care? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Support staff interview tool Number 9 Question Did you ever participate in facility meetings to discuss the quality of the services to adolescents and plan actions for improvement? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

Aggregate support staff score

Overall score on Criterion 65 Category 1 2 3 Aggregate facility manager score Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–2 0–1 0–1 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 65

(

Total score 4

)

× 100

CRITERION 66. Health-care providers and support staff receive supportive supervision in areas identified during self-assessments. Health facility manager interview tool Number 8a Question Do you regularly conduct supportive supervision visits with a focus on adolescent health care: To facility health-care providers? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 105

Number 8b

Question Do you regularly conduct supportive supervision visits with a focus on adolescent health care: To support staff?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

8c

Do you regularly conduct supportive supervision visits with a focus on adolescent health care: To outreach workers?

1=Yes, 0=No

Aggregate health facility manager score

Direct observation (checklist) tool Number 9l Question Check to see the following registers, tools and records. Records of accomplished supportive supervision visits focused on adolescent health care Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 26a Question Did your mentor/supervisor ever observe a consultation by you with an adolescent client to help you to improve the quality of care? Did your mentor/supervisor ever advise you how to improve the quality of care for adolescent clients? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

26b

1=Yes, 0=No

Aggregate health-care provider score

Overall score on Criterion 66 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–3 0–1 0–2 0–6 0 to 100% Score

Absolute total score Relative score for Criterion 66

(

Total score 6

)

× 100

106 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

CRITERION 67. Good performance is recognized and rewarded.

Health-care provider interview tool Number 32a Question Have you, or any of your colleagues, ever been rewarded for high performance? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Support staff interview tool Number 12a Question Have you, or any of your colleagues, ever been rewarded for high performance? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

Aggregate support staff score

Overall score on Criterion 67 Category 1 2 Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 67

(

Total score 2

)

× 100

CRITERION 68. Facility’s reports to district include data on cause-specific utilization of services by adolescents that is disaggregated by age and sex. Health facility manager interview tool Number 13 Question Do facility reports to the district include data on cause-specific service utilization by adolescents that is disaggregated by age and sex? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Aggregate health facility manager score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 107

Direct observation (checklist) tool Number 9m Question Check to see the following registers, tools and records. Reports to the district on cause-specific service utilization by adolescents that include data disaggregated by age and sex Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 29b Question Do you report data on service utilization by adolescents, along with the sex of adolescents? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Aggregate health-care provider score

Overall score on Criterion 68 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 68

(

Total score 3

)

× 100

CRITERION 69. Facility’s reports to districts on quality of care have a focus on adolescents.

Health facility manager interview tool Number 14 Question Do facility reports to the district on quality of care have a focus on adolescents? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Aggregate health facility manager score

108 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Direct observation (checklist) tool Number 9n Question Check to see the following registers, tools and records. Reports to the district on quality of care that have a focus on adolescents Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Overall score on Criterion 69 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 69

(

Total score 2

)

× 100

CRITERION 70. Health facility staff feel supported by supervisors and motivated to comply with the standards.

Health-care provider interview tool Number 31b Question Do you feel you have enough support from your supervisor to improve the quality of care for adolescents? Do you feel you have the motivation to improve the quality of care for adolescents, and to comply with quality standards? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

31c

1=Yes, 0=No

Aggregate health-care provider score

Support staff interview tool Number 11b Question Do you feel you have enough support from your supervisor to improve the quality of care for adolescents? Do you feel you have the motivation to improve the quality of care for adolescents, and to comply with quality standards? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of support staff interviewed Total number of responses coded as “1” divided by the total number of support staff interviewed Total score

11c

1=Yes, 0=No

Aggregate support staff score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 109

Overall score on Criterion 70 Category 1 2 Aggregate health-care provider score Aggregate support staff score Minimum – Maximum 0–2 0–2 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 70

(

Total score 4

)

× 100

CRITERION 71. The governance structure of the facility includes adolescents.

Health facility manager interview tool Number 19b Question Does this structure/board include adolescents? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

Aggregate health facility manager score

Overall score on Criterion 71 Category 1 Aggregate facility manager score Minimum – Maximum 0–1 0–1 0 to 100% Score

Absolute total score Relative score for Criterion 71

(

Total score 1

)

× 100

CRITERION 72. There is a policy in place to engage adolescents in service planning, monitoring and evaluation.

Health facility manager interview tool Number 7m Question Do you have any of the following guidelines/SOPs in your facility? SOPs on how to involve adolescents in the planning, monitoring and evaluation of health services and service provision Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

110 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Number 7n

Question Do you have any of the following guidelines/SOPs in your facility? SOPs on how to involve vulnerable groups of adolescents in the planning, monitoring and evaluation of health services and service provision

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of facility managers interviewed

Aggregate health facility manager score

Total score

Direct observation (checklist) tool Number 14l Question Check to see if there are the following guidelines/SOPs: SOPs on how to involve adolescents in the planning, monitoring and evaluation of health services and service provision 14m Check to see if there are the following guidelines/SOPs: SOPs on how to involve vulnerable groups of adolescents in the planning, monitoring and evaluation of health services and service provision Aggregate direct observation (checklist) score Total score 1=Yes, 0=No Score 1 for “Yes” or 0 for “No” Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Overall score on Criterion 72 Category 1 2 Aggregate facility manager score Aggregate direct observation (checklist) score Minimum – Maximum 0–2 0–2 0–4 0 to 100% Score

Absolute total score Relative score for Criterion 72

(

Total score 4

)

× 100

CRITERION 73. Health-care providers are aware of laws and regulations that govern informed consent, and the consent process is clearly defined by facility policies and procedures in line with laws and regulations. Health facility manager interview tool Number 7f Question Do you have any of the following guidelines/SOPs in your facility? Guidelines/SOPs on informed consent Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 111

Direct observation (checklist) tool Number 14e Question Check to see if there are the following guidelines/SOPs: Guidelines/SOPs on informed consent Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 8d Question Are you aware of the following SOPs/ guidelines: Guidelines/SOPs on informed consent? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 73 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 73

(

Total score 3

)

× 100

CRITERION 74. The health facility carries out regular activities to identify adolescents’ expectations about the service and to assess their experience of care, and it involves adolescents in the planning, monitoring and evaluation of health services. Health facility manager interview tool Number 9a Question Does your facility regularly conduct self-assessments: To identify adolescents’ expectations about the services in the facility? 9b Does your facility regularly conduct self-assessments: To find out about adolescents’ experience of care? Aggregate health facility manager score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

112 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Health-care provider interview tool Number 16a Question Have you ever involved any of the following groups in these activities: Adolescents in the planning, monitoring and evaluation of health services? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Overall score on Criterion 74 Category 1 2 Aggregate facility manager score Aggregate health-care provider score Minimum – Maximum 0–2 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 74

(

Total score 3

)

× 100

CRITERION 75. Health-care providers provide accurate and clear information on the medical condition and management/treatment options, and explicitly take into account the adolescent’s decision on the preferred option and follow-up actions. Adolescent client exit interview tool Number 17o Question Today, during your consultation or counselling session: Do you feel that the health information provided during the consultation was clear, and that you understood it well? 17p Today, during your consultation or counselling session: Did the provider ask you if you agree with the treatment/procedure/solution that was proposed? Aggregate adolescent client score 1=Yes, 0=No Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total score

Direct observation (client-provider interaction) tool Number 14 Question If an informed consent from a third party was required, was adolescent assent to the service/procedure also obtained? Response 1=Yes, 0=No, 6=Not relevant Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 113

Number 16d

Question During the consultation did the service provider do the following: Provide accurate and clear information on the medical condition?

Response 1=Yes, 0=No

Score Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made

16e

During the consultation did the service provider do the following: Provide accurate and clear information on the management/treatment options?

1=Yes, 0=No

16f

During the consultation did the service provider do the following: Ask the adolescent client what are his/her preferences for the management/treatment options?

1=Yes, 0=No

16g

During the consultation did the service provider do the following: Provide accurate and clear information on follow-up actions?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made Total number of responses coded as “1” divided by the total number of observations made

16h

During the consultation did the service provider do the following: Ask the adolescent client what are his/her preferences for the follow-up actions?

1=Yes, 0=No

16i

During the consultation did the service provider do the following: Ask the adolescent client whether he/she has any problem understanding the treatment that is being provided?

1=Yes, 0=No

16j

During the consultation did the service provider do the following: Check the adolescent client’s understanding of the information provided by asking probing questions?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of observations made

16k

During the consultation did the service provider do the following: Use audio-visual material to explain anatomy, disease, or other, as relevant to the topic of the consultation?

1=Yes, 0=No

Total number of responses coded as “1” divided by the total number of observations made

16m

During the consultation did the service provider do the following: Explain the results of the physical examination to the client?

1=Yes, 0=No, 6=Not relevant

Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

Aggregate direct observation (client-provider interaction) score

114 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Health-care provider interview tool Number 21f Question When you see an adolescent client for services or counselling do you: Obtain, in cases when an informed consent from a third party is required, the adolescent’s assent to the service/procedure? Aggregate health-care provider score Response 1=Yes, 0=No, 6=Not relevant Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0”

Total score

Adolescent in the community interview tool Number 19 Question Did you feel the information provided during the consultation was clear, and that you understood it well? Did the provider ask you if you agreed with the treatment, procedure or solution that was proposed? Response 1=Yes, 0=No, 7=Can’t remember 1=Yes, 0=No, 7=Can’t remember Score Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total number of responses coded as “1” divided by the sum of responses coded “1” and “0” Total score

20a

Aggregate adolescent in the community score

Overall score on Criterion 75 Category 1 2 3 4 Aggregate adolescent client score Aggregate direct observation (client-provider interaction) score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–2 0–10 0–1 0–2 0–15 0 to 100% Score

Absolute total score Relative score for Criterion 75

(

Total score 15

)

× 100

CRITERION 76. The health facility carries out activities to build adolescents’ capacity in certain aspects of healthservice provision. Health facility manager interview tool Number 17c Question Do you have budget to ensure: Training of adolescents in providing certain services (e.g. health education for peers, counselling)? Aggregate health facility manager score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of facility managers interviewed Total score

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 115

Direct observation (checklist) tool Number 13i Question Check to see training records/reports for the following topics. Training of adolescents in providing certain services (for example, health education for peers, counselling) Aggregate direct observation (checklist) score Total score Response 1=Yes, 0=No Score Score 1 for “Yes” or 0 for “No”

Health-care provider interview tool Number 15b Question Have you ever trained any of the following groups in these areas: Adolescents in providing certain services, for example, health education for peers, counselling? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed

Total score

Overall score on Criterion 76 Category 1 2 3 Aggregate facility manager score Aggregate direct observation (checklist) score Aggregate health-care provider score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 76

(

Total score 3

)

× 100

CRITERION 77. Adolescents are involved in planning, monitoring and evaluation of health services.

Adolescent client exit interview tool Number 23b Question Today, or in other occasions, were you or your friends approached to help facility staff in planning health services, or any activity to improve the quality of services such as surveys, participating in meetings to discuss the quality of care, or any other? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Aggregate adolescent client score

Total score

116 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Adolescent in the community interview tool Number 28b Question Have you or your friends ever been approached to help facility staff in planning health services, or any activity to improve the quality of services such as surveys, or participating in meetings to discuss the quality of care? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total score

Aggregate adolescent in the community score

Overall score on Criterion 77 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 77

(

Total score 2

)

× 100

CRITERION 78. Adolescents are involved in decisions regarding their own care.

Adolescent client exit interview tool Number 17q Question Today, during your consultation or counselling session: Overall, did you feel that you were involved in the decisions regarding your care? For example, you had a chance to express your opinion or preference for the care provided, and your opinion was listened to, and heard? Aggregate adolescent client score Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed

Total score

Adolescent in the community interview tool Number 20b Question Overall, did you feel that you were involved in the decision regarding your care–for example, did you have a chance to express your opinions or preferences for the care provided, and did you feel that your opinion was listened to, and heard? Response 1=Yes, 0=No, 8=Don’t know Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total score

Aggregate adolescent in the community score

Overall score on Criterion 78 Category 1 2 Aggregate adolescent client score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–1 0–2 0 to 100% Score

Absolute total score Relative score for Criterion 78

(

Total score 2

)

× 100

CRITERION 79. Adolescents are involved in certain aspects of health service provision.

Adolescent client exit interview tool Number 23a Question Today, or in other occasions, were you or your friends approached to help staff in working with adolescents in this adolescent clinic/health facility? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescent clients interviewed Total score

Aggregate adolescent client score

Health-care provider interview tool Number 16b Question Have you ever involved any of the following groups in these activities: Adolescents in any aspects of service provision? Aggregate health-care provider score Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of health-care providers interviewed Total score

Adolescent in the community interview tool Number 28a Question Have you or your friends ever been approached to help staff in working ­ with adolescents in the nearby facility? Response 1=Yes, 0=No Score Total number of responses coded as “1” divided by the total number of adolescents in the community interviewed Total score

Aggregate adolescent in the community score

118 GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS

Overall score on Criterion 79 Category 1 2 3 Aggregate adolescent client score Aggregate health-care provider score Aggregate adolescent in the community score Minimum – Maximum 0–1 0–1 0–1 0–3 0 to 100% Score

Absolute total score Relative score for Criterion 79

(

Total score 3

)

× 100

GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS 119

©SHREYA NATU

For more information, please contact: Department of Maternal, Newborn, Child and Adolescent Health (MCA) World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland Tel.: +41 22 791 3281 Fax: +41 22 791 4853 Email: mncah@who.int www.who.int/maternal_child_adolescent/en

ISBN 978 92 4 154933 2