Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach

Figures & data

Table 1. Participants, sources of data and methods for data collection

	Interviews and FGDs: participants and methods	Other data collected and type
National level	12 individual interviews: national stakeholders	Secondary data:National guidelines (old and new)Report Evaluation of AFSReport Evaluation of training workshops with health providersForm Clinical history for adolescents
Los Barrios	Four individual interviews: medical doctor, nurse, statistic department, NGO representativeOne FGD (six participants) members of youth organisation in the area	Secondary data:Report evaluation and systematisation Los BarriosReport elaborated on young people, sexuality and masculinitiesObservations:Observation in waiting room and during consultation with adolescentsInformal interviews with users waiting: young men, young women, adult women
Nueva Ciudad	Five individual interviews: medical doctor, administrator, statistics department, paediatrician, NGO representativeOne FGD (eight participants) youth group working with AFS Nueva Ciudad	Secondary data:Report Internal evaluationReports of workshops with young peopleAnnual plansPresentations from health centre and youth group.Observations:General waiting roomAdolescents’ waiting room areaYouth group roomConsultation with adolescents-paediatricianTriageInformal interviews with users waiting: young girls, mothers
Chambil	Four individual interviews: medical director, nurse, midwife, MoH provincial representativeOne FGD (six participants) health team ChambilOne FGD (seven participants) youth group working with AFS Chambil	Secondary data:Annual reportsReports of workshops with youth organisationTraining materials for young peopleObservations:Workshop with health providers-adolescents’ mental healthObservation in waiting roomConsultation with adolescents-midwifeInformal interviews in waiting room: with young women, young men, adolescent mother after consultation

Table 2. Main characteristics of the local context in the three explored cases

Los Barrios	Nueva Ciudad	Chambil
Small health centre (HC) in a marginalised area of a big cityStarted as women's HC: strong support from community and local NGO expert on gender and sexual and reproductive healthDifferentiated services for adolescents since 2002: one doctor attending during morningsHealth promotion with schoolsNo adolescents’ organisation at HCGeneral practitioner (GP) in charge is well-sensitised and trained	Large HC, including some medical specialtiesAFS started in 2004 with support from an international NGOCurrently there is an ‘adolescents’ zone’ with the medical office for ‘Growth and Development’ attended by a paediatricianAdolescents’ reproductive health is dealt with in the obstetric office, together with adult womenHC works with adolescents’ organisation and schoolsAll members of staff have been trained and they incorporate the newcomers	Small HC in marginalised area of small cityAFS started in 2005 with support from an international development projectNo differentiated services, but certain arrangements for facilitating access by adolescentsHC works with adolescents’ organisation and schoolsAll members of staff have been trained and they incorporate the new comers

Table 3. Main outcomes in the three cases explored

	Los Barrios	Nueva Ciudad	Chambil
Previous evaluation MoH (2007)	95%Consolidated developmentAll the components implemented effectively and a long time experience working with adolescents, with the support of an NGO. Adolescents participate actively during the entire consultation process, and staff is empowered. Recommended as centre of excellence for internships for other providers	96%Consolidated developmentAll components adequately implemented. They have their own model of care. All the staff have received 6 months of training and half of the staff involved in providing care for adolescents at least for 1 year.Recommended as centre of excellence for internships for other providers	96%Consolidated developmentAll components implemented efficiently, and with good quality.Recommended as centre of excellence for internships for other providers
Outcome 1	High number of adolescentsDiversity of adolescents’ profiles accessing the HC with a diversity of consultations	Adolescents come to the health centre.Few consultations regarding SRH. Work with schools.There is an adolescents’ group	Not highly accessed by adolescents; the majority are pregnant adolescents or adolescent mothers.Staff from the facility visits some schools located in the vicinity.There is an adolescents’ group that gathers periodically in the HC
Outcome 2	Constantly adapting to respond to adolescents’ needs.Good reputation that attract many adolescents.No barriers for contraceptive access to adolescents.Referral system	Confidentiality and privacy ensured.Variety of contraceptives not always available.Majority of adolescents get consultations that focus on ‘Growth and development’ and less on SRH.Psychological and social services.Referral system working	Not many consultations from adolescents, besides the ones from pregnant adolescents and adolescent mothers. Contraceptives of different types are not always availableWarmth relationship between pregnant adolescents and midwife.Staff willing to smooth consultation process when adolescents’ arrive
Outcome 3	Adolescent boys access the services. Gender perspective incorporated during consultation.Gender based violence and sexual violence assessed and referral system exist	Gender approach not integrated.Direct strategies to attract boys not implemented.Part of a network against violence against women, but few cases detected.Homophobia is not addressed	Access for young men was not perceived as relevant.Adolescents who attend the HC were pregnant girls or mothering girls.Violence against women not assessed during consultation with adolescents.Homophobic remarks