title: Evaluating youth-friendly health services: young people's perspectives from a simulated client study in urban South Africa.
abstract: BACKGROUND
  Few§These authors contributed equally to this work. youth-friendly health services worldwide have been scaled up or evaluated from young people's perspectives. South Africa's Youth Friendly Services (YFS) programme is one of the few to have been scaled up. This study investigated young people's experiences of using sexual and reproductive health services at clinics providing the YFS programme, compared to those that did not, using the simulated client method.
  
  
  METHODS
  Fifteen primary healthcare clinics in Soweto were randomly sampled: seven provided the YFS programme. Simulated clients conducted 58 visits; young men requested information on condom reliability and young women on contraceptive methods. There were two outcome measures: a single measure of the overall clinic experience (clinic visit score) and whether or not simulated clients would recommend a clinic to their peers. The clinic visit score was based on variables relating to the simulated clients' interactions with staff, details of their consultation, privacy, confidentiality, the healthcare workers' characteristics, and the clinic environment. A larger score corresponds to a worse experience than a smaller one. Multilevel regression models and framework analysis were used to investigate young people's experiences.
  
  
  RESULTS
  Health facilities providing the YFS programme did not deliver a more positive experience to young people than those not providing the programme (mean difference in clinic visit score: -0.18, 95% CI: -0.95, 0.60, p=0.656). They were also no more likely to be recommended by simulated clients to their peers (odds ratio: 0.48, 95% CI: 0.11, 2.10, p=0.331). More positive experiences were characterised by young people as those where healthcare workers were friendly, respectful, knew how to talk to young people, and appeared to value them seeking health information. Less positive experiences were characterised by having to show soiled sanitary products to obtain contraceptives, healthcare workers expressing negative opinions about young people seeking information, lack of privacy, and inadequate information.
  
  
  CONCLUSIONS
  The provision and impact of the YFS programme are limited. Future research should explore implementation. Regular training and monitoring could enable healthcare workers to address young people's needs.
authors.affiliation: Department of Infection and Population Health, University College London, London, UK; Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; r.geary@ucl.ac.uk.
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Geary
authors.affiliation: Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Emily L
authors.initials: EL
authors.lastname: Webb
authors.affiliation: Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Lynda
authors.initials: L
authors.lastname: Clarke
authors.affiliation: MRC/Wits Developmental Pathways for Health Research Unit, Department of Pediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Shane A
authors.initials: SA
authors.lastname: Norris
mesh_terms: D000293:Adolescent; D001291:Attitude of Health Personnel; D003267:Contraception / Q000523:psychology*; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D008297:Male; D016544:Patient Simulation; D012749:Sexually Transmitted Diseases / Q000175:diagnosis; D012959:Socioeconomic Factors; D013019:South Africa; D014505:Urban Population
keywords: South Africa; adolescent health services; simulated client; youth friendly