title: Impact of accessible sexual and reproductive health care on poor and underserved adolescents in Managua, Nicaragua: a quasi-experimental intervention study.
abstract: BACKGROUND
  The objective of this study was to evaluate a competitive voucher program intended to make sexual and reproductive health care (SRHC) accessible to adolescents from disadvantaged areas of Managua.
  
  
  METHODS
  A quasi-experimental intervention study was performed in which 28,711 vouchers that gave free access to SRHC in 20 health centers, were distributed to adolescents. To evaluate the impact, community sampling took place in markets, neighborhoods, and outside schools where self-administered questionnaires were distributed. The study comprised a random sample of 3,009 female adolescents, ages 12 to 20 years old, 904 voucher receivers and 2,105 nonreceivers. Their use of SRHC, and knowledge and use of contraceptives and condoms were measured.
  
  
  RESULTS
  Voucher receivers had a significantly higher use of SRHC compared with nonreceivers, 34% versus 19% (adjusted odds ratio, 3.1; 95% confidence interval, 2.5-3.8). The highest influence was seen among respondents at schools, where use was 24% relative to 6% in nonreceivers (adjusted odds ratio, 5.9; 95% confidence interval, 3.7-9.5). Voucher receivers answered significantly more questions correctly that were related to knowledge of contraceptives and sexually transmitted infections than nonreceivers. At schools, sexually active voucher receivers had a significantly higher use of modern contraceptives than nonreceivers, 48% versus 33% (adjusted odds ratio, 2.3; 95% confidence interval, 1.2-4.4); and in neighborhoods, condom use during last sexual contact was significantly greater among voucher receivers than nonreceivers (adjusted odds ratio, 2.5; 95% confidence interval, 1.4-4.5).
  
  
  CONCLUSIONS
  The voucher program succeeded in increasing access to SRHC for poor and underserved girls. The needs of adolescents were met with a relatively simple intervention through existing health facilities. Many adolescents appeared willing to protect themselves against the risks of sexual intercourse. This suggest that access to SRHC can play an important role in changing youth behavior and increase the use of contraceptives and condoms.
authors.affiliation: Instituto CentroAmericano de la Salud, Managua, Nicaragua. liesbethmeuwissen@yahoo.com
authors.forename: Liesbeth E
authors.initials: LE
authors.lastname: Meuwissen
authors.forename: Anna C
authors.initials: AC
authors.lastname: Gorter
authors.forename: André J A
authors.initials: AJ
authors.lastname: Knottnerus
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior; D016497:Adolescent Health Services / Q000706:statistics & numerical data*; D003151:Community Health Centers / Q000191:economics; D003267:Contraception; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008507:Medically Underserved Area; D009527:Nicaragua; D010353:Patient Education as Topic; D011247:Pregnancy; D011253:Pregnancy in Adolescence / Q000517:prevention & control; D012749:Sexually Transmitted Diseases / Q000517:prevention & control; D016896:Treatment Outcome