Adolescent Friendly Health Clinics (AFHCS) in India and their compliance with government benchmarks: A scoping review

Design

To map the compliance of current adolescent healthcare facilities based on the RKSK benchmark set by GoI,¹⁷ we adopted a scoping review design¹⁸ by using Arksey and O’Malley’s five stage scoping review framework.¹⁹

Stage 1: Identify the research question

Identifying the research question is the first step in carrying out a scoping review, according to Arksey & O’Malley.¹⁹ Therefore, our scoping review addressed the following research question in an effort to synthesise the available knowledge in this field:

What is known about the compliance to the RKSK benchmark set by the GOI in various regions of India based on the available literature?

Stage 2: identifying relevant studies

Our search strategy was established after conducting preliminary research to understand search terms and keywords. We looked up the terms “AFHC” AND “Adolescent Friendly Health Clinics,” “RKSK,” “compliance,” and “India” in PubMed, Scopus, and Google Scholar (Table 1).

Stage 3: Selection of literature: Inclusion criteria

The systematic inclusion of the papers was done in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations.²⁰ Our search approach identified twenty-four papers, which were then imported into Mendeley desktop 1.19.5. Ten duplicate items were deleted, leaving Fourteen articles to be screened. We screened titles, abstracts, and references using the criteria described below. The last search was carried out by two researchers from July 2022 to December 2022. Benchmark of AFHCs as per GOI’s guidelines was identified as the outcome of the studies.

3.1. Types and scope of studies

In this review, studies using both quantitative and qualitative approaches were included from every research setting and region in India. We looked for papers that had been published in India between 2014 and December 2022 and had any information on the standard for AFHCs according to the Indian government. The studies conducted before 2014 were excluded, as that was the year the RKSK was launched. A priori, no language or publishing status restrictions were established.

3.2. Key concepts

Key concepts pertaining to the AFHC benchmarks established by the GOI under RKSK were covered in this review.

3.3. Participants

This review focused on various level health facilities which provide AFHC services to adolescents aged 10-19 years.

Following this, seven full-text papers were evaluated, and four papers were further omitted due to incorrect outcomes and full-text non-availability. Our review did not impose any geographic limitations in order to gather as many data as feasible and take diversity into account. We only considered articles that had undergone peer review. Papers without an English translation were not included in our analysis. However, a snowball search strategy was used to retrieve all maximum possible articles.

3.4. Stage 4: Data extraction

Data related to the benchmarks was extracted on the excel sheet and before retrieving the data, the excel sheet was piloted by the researchers of the team. Information extraction included seven benchmarks set by MoHFW-GOI including Infrastructure, clean, bright and colourful, accessibility (distance and convenient working hours), awareness about the clinic and range of services it provides (Information, Education and Communication, Proper Sinages), non-judgmental and competent health service providers, privacy and confidentiality, awareness of the services to the community members, their need and referral from the periphery/community to the higher facilities and speciality clinics.¹⁷ Two reviewers (SB and DB) looked over the full texts and abstracts of all the publications as well as their citations to determine each article's eligibility. Two authors independently evaluate the articles and extracted the data for this review based on the set benchmarks of GOI. Disagreements were resolved by discussion with the third author.

3.5. Stage 5: Collating, Summarizing and Reporting the Results

To summarise our data, we used the author and year of publication, AFHC benchmarks, and clinic awareness. This study presents findings related to infrastructure, community awareness of the services provided, referral from the periphery/community and further referral linkages with higher facilities and specialty clinics, privacy and confidentiality, nonjudgmental and competent health service providers, and accessibility as AFHC benchmark parameters. However, clinic awareness also included the provision of Information, Education and Communication (IEC) and signage. A review synthesis was carried out, taking into account the differences between the various studies in terms of study aims, design, and conclusions.

Selection of studies

We found 24 papers from PubMed(n=0), Scopus(n=14), and Google scholar(n=10) in the initial database search. After removing the duplicates, 14 articles were screened, seven articles were excluded based on title and abstract screening. Only seven articles were eligible for full-text screening. While five articles were included during full-text screening by checking the references. Thus, a total of 12 articles were reviewed and finally, only eight articles were included in this review (Figure 1).

Figure 1. PRISMA flow diagram of included studies in review.

Characteristics of studies

Eight studies from the year 2014 to 2022 were identified and included in the review. Of eight studies, six were cross-sectional, 1 cohort and 1 qualitative was included for review. The included studies had been conducted in different geographical locations of the country like Kashmir,²¹ Ladakh,²¹ Leh,²² Uttar Pradesh,²³ Ahemdabad,²⁴ Jharkhand,^25,26 Maharastra,²⁵ Rajasthan,^15,25 Madhya Pradesh,²⁷ Delhi,²⁶ Haryana,²⁶ Punjab,²⁶ and Uttrakhand.²⁶ They covered AFHC¹⁵ at various levels of establishment, for example, at CHC,^25,27 district hospital²¹ and sub-district hospital.^21,25 These studies included, either ‘exit interviews’ of patients^23–25,27 availing services at AFHCs or interviews of health care providers/counsellors/staff²² dealing with adolescents in AFHC and ‘Mystery clients’,^25,26 to gather information about AFHC.

Compliance of AFHCs with benchmarks enlisted under the RKSK

Privacy and confidentiality

Out of the eight studies, seven studies evaluated the privacy and confidentiality aspect of AFHCs. Of the available seven studies, six studies reported that privacy and confidentiality in AFHCs were not maintained (Table 2) and below is the evidence from the independent studies to support this statement.

Qualitative assessment emphasised seven of the fifteen clients from Jharkhand, Maharashtra and Rajasthan felt that their conversation with the MO or other staff could have been overheard by others. In addition, four of the nine clients who underwent a physical examination felt that others could have seen them while being examined by the MO.²⁵ Similarly, interaction with mystery clients of Rajasthan reported disturbance from the staff and other patients visiting the clinic during their counselling sessions. In four out of 24 visits, these clients reported that someone was present (besides the practitioner/counsellor) during the sessions. In as frequent as half of the visits (12/24), the clients reported people coming in between the counselling sessions. This was mainly due to the location of the clinic which led to disturbance and visibility by others.¹⁵

Quantitative analysis in the identified studies also showed that confidentiality and privacy were breached. The majority of adolescents (90.91%) did not receive privacy during the consultation and curtains were available only during counselling of 42.42% of adolescent girls²⁴ during their visits to AFHCs of Ahmedabad. During the clinic's observation, privacy and confidentiality were provided in only 63.6% of the facilities.²⁴ Similarly, in RKSK facilities of Madhya Pradesh, curtains were not there (33%) and conversation could be heard from outside (40%).²⁷ A six-state (Delhi, Haryana, Himachal Pradesh, Jharkhand, Punjab, Uttrakhand) evaluation of AFHCs showed that only 35% of them maintained privacy; with the least being in AFHCs of Himachal Pradesh (0%).²⁶ Adolescents (69%) from Ahmedabad believed that there should be an opportunity for separate private discussions with doctors at AFHCs.²⁸

On the contrary, there was only one study from Kashmir and Ladakh that showed privacy was maintained. Results showed that 75% of AFHCs operational under RKSK had a dedicated space and the consultation room ensured the privacy of the clients.²¹

Infrastructure (clean, bright and colourful)

Four out of eight studies did not evaluate the AFHC infrastructure like cleanliness and brightness. The remaining four studies evaluated this benchmark and three studies reported that AFHC infrastructure was maintained well and in only one study the benchmark was not maintained, below is the evidence.

As per the qualitative results from a study conducted in three states, all the adolescents found the facility to be clean.²⁵ Similar results were reported by all the adolescents (100%) accessing the AFHC in Ahmedabad.²⁴ In another study 17 out of the 24 i.e., 70% of adolescents reported the clinic to be ‘overall clean from inside and outside highlighting cleanliness in these clinics.¹⁵ On other hand, a study conducted in 10 districts of Madhya Pradesh showed that only 60% of the clinics were clean.²⁷

Non-judgmental and competent health service providers

Another benchmark of the AFHC is to have non-judgemental and competent healthcare providers. Out of eight studies, only three studies have highlighted the finding around this benchmark. Out of three studies, one study did not meet the benchmark.

One-third of the adolescents in a study reported some counsellors’ behavior was “judgemental and biased” as the counselor had a judgemental attitude towards unmarried adolescent girls engaging in premarital sexual activity.¹⁵

Although, in one study almost all adolescent clients, regardless of their sex, or state of residence, reported that the healthcare provider had greeted them cordially when they entered the consultation room (21 of the 24 visits).²⁵ Similarly, in another study adolescents of Ahmedabad reported that 93.9% of health care providers were welcoming during their visits.²⁴

Accessibility (distance and convenient working hours)

The accessibility of these clinics is defined by the distance and the convenient working hours. Out of eight studies, three studies did not evaluate the accessibility of AFHCs. The remaining five studies evaluated this benchmark, and all (n=5) showed that the clinics were accessible to adolescents, below is the supportive evidence.

According to the result of the study conducted in Ahmedabad, 87.8% of adolescents reported that time and days are convenient to seek services²⁴ and similarly 100% of adolescents reported that time was convenient.²³ Similarly, when evaluating the AFHC of Kashmir²¹ and Madhya Pradesh it showed that they were functional on all days.²⁷ Concerning the distance, AFHC was 5-10 kilometers away from the villages and also the respondents reported that these facilities were easily accessible.²⁵

Awareness about the clinic and range of services (IEC, Proper Signages)

Another important variable is awareness of the clinic assessed through signboards and IEC material displayed in the AFHC. Out of eight studies, three studies did not evaluate this benchmark. Of the five studies, four studies showed that the IEC material benchmark was not fulfilled.

Evidence from the studies showed that reading material was available but was readable by only 56.5% of adolescents and less than half of adolescents (43.4%) reported that the material was interesting.²⁹ In results derived through observations in another study, no IEC material was displayed in the AFHC.²⁴ AFHC evaluation from six states of India showed that only 44% of clinics displayed material.²⁶ Similarly, the adolescents reported that only limited IEC material on SRH was displayed in the waiting area of all the AFHCs.¹⁵

On the contrary, only one evaluation from Kashmir and Ladakh regions showed a majority (83.3%) of the facilities had IEC material available.²¹

Regarding the availability of signages, only four studies evaluated the availability of signboards, and the findings gave a mixed picture (two studies met the benchmarks and the other two did not). In one evaluation, it showed that signboards were only seen in one-fourth of AFHC²⁴ and another evaluation showed that 67% of AFHC from 10 districts of Madhya Pradesh had sign boards.²⁷ On the contrary, evaluation of AFHCs from Ahmedabad showed signboards were available in 100% of the AFHCs²¹ and similar findings were seen when AFHCs from Jammu and Kashmir were observed.²²

Referrals and community members awareness

Community members’ awareness of the service provided has not been evaluated in the included studies. Another benchmark is the referral from the periphery/community to the higher facility. Out of eight studies, six studies have not evaluated the referral mechanism. The remaining two evaluated, out of which in one study mystery clients reported that they had been referred to a higher facility for SRH issues.²⁵ Similarly in another study, all counsellors reported referring cases of substance abuse, alcohol addiction, STIs, menstrual pain, unwanted pregnancy, and nocturnal emissions to more qualified healthcare providers but the adolescents reported only a few of them were referred to doctors by the counsellors for nocturnal emissions, STIs and teenage pregnancy.¹⁵