Initiative

and Action for Advancing and in National Guidelines on Promoting Access of Young People to Adolescent- and Youth-Friendly Services in Primary Health Care Facilities in provides a road map on how to engage adolescents and other young people, who are the principal stakeholders, in promoting access to adolescent sexual reproductive health (ASRH) at the lowest level of healthcare. It is expected that the implementation of the guidelines will improve the participation of young persons in and their access to adolescent- and youth-friendly services at the primary health care level in

In recognition of the necessary synergy needed between the provision and the utilization of AYFHS, the Federal Ministry of Health, in collaboration with partners, developed the National Guidelines on Promoting the Access of Young People to Adolescent and Youth-Friendly Services in Primary Health Care Centres. While the National Guidelines for the Integration of AYFHS into Primary Health Care Facilities in Nigeria is aimed at improving the availability of primary health care facilities for young persons this document serves as a tool for mobilizing youth to access these services.
Young people between the ages of 10 and 24 years constitute 33.6% of the country's population. This makes them integral to Nigeria's socio-political and economic development. Lack of adequate sexual and reproductive health information and services makes young people vulnerable to risky behaviours and negative health outcomes. This document is informed by the need to create awareness on available youth-friendly health services in the community, in line with the Action Plan for Advancing Young People's Health and Development in Nigeria.
This document provides programme planners, implementers, and health managers at various levels with strategic considerations and broad guidance for actions needed to improve young people's demand for and utilization of available adolescent and youth friendly health services. I hereby recommend these guidelines for use not only at primary health care level, but at all levels of health care delivery in Nigeria to improve access to quality adolescent-and youth-friendly health services for all young people in Nigeria.

P R E F A C E
The hope for the development of any nation lies in her youth. According to the 2006 national census, one-third of the total population of Nigeria is young people between ages 10 to 24. Although adolescents and youths are generally considered physically healthy, they are vulnerable to a number of unique health problems such as HIV and AIDS, STIs, unsafe abortion, drug abuse and addiction, mental disorders, unplanned pregnancies with its consequences, sexual violence and other associated health issues resulting from early marriage.
Lack of information and limited access to adolescent and youth-friendly services at the community level have been identified as contributory factors to the poor reproductive health status of young people in Nigeria. Adolescents and other young people provide an opportunity for investment in human development. Their resourcefulness and energy, when appropriately channeled have been shown to improve their standard of living and that of their families and communities.
Community participation, health promotion, social support and the empowerment of young people are critical to achieving sustainable improvements in reproductive health care. Inschool and out-of-school based information education communication (IEC); peer education; community-based IEC; outreach initiative; enter-education; mass media; community participation and social mobilization as well as advocacy singly and collectively help to generate demand for AYFHS. The National Guidelines on Promoting Access of Young People to Adolescent-and Youth-Friendly Services in Primary Health Care Facilities in Nigeria provides a road map on how to engage adolescents and other young people, who are the principal stakeholders, in promoting access to adolescent sexual reproductive health (ASRH) at the lowest level of health care.
It is expected that the implementation of the guidelines will improve young person's participation in and access to adolescent-and youth-friendly services at the primary health care level in Nigeria.

A C K N O W L E D G M E N T S
The conceptualization and publication of the National Guidelines on Promoting Access of Young People to Adolescent and Youth Friendly Services in Primary Health Care Facilities in Nigeria was a thorough task which could not have been accomplished without the invaluable contributions of numerous stakeholders.
Our appreciation goes to the Honorable Minister of Health, Professor C.O. Onyebuchi Chukwu and the permanent secretary, Ambassador Sani Bala, who provided the enabling environment for the development and production of this landmark document. Profound gratitude also goes to Dr. Chris Ugboko, head, Gender, Adolescent/School Health and Elderly Care and the Adolescent/School Health team, led by the national coordinator, David O. Ajagun for the great coordination of activities that led to the production of this document.
The success of this publication would not have been possible without the sound and consistent guidance of the consultant Professor Adesegun Fatusi, chairman, National Working Group on Adolescent Health and Development whose great knowledge and experience was an invaluable resource.
We express our deep appreciation to the Women Friendly Initiative (WFI) for leading the effort which was made possible through a grant from Ford Foundation. It is also expedient to record our gratitude and appreciation to stakeholders who helped to make this document a reality: National Primary Health Care Development Agency (NPHCDA), Federal Ministry of Education (FME), and other line ministries; Planned Parenthood Federation of America, Global Division; and adolescents and young people who form the focus of this intervention.
Furthermore, we would like to express our limitless gratitude to various youth-led and youth-focused organizations for their input. Above all, we would like to express our gratitude to the Almighty God without whose benevolence; all our efforts would be in vain.

Background
Access to health services plays a significant role in young people's health. Improved access to health care for young people has been documented to reduce risky behaviour, improve health status indicators and serve as an indicator of equity. In line with the provisions of relevant 1 nationalpolicy documents, Nigeria has initiated some key steps towards improving the availability and quality of adolescent and youth-friendly health services (AYFHS). In particular, between 2012 and 2013, the country developed the National Standards and Minimum Package for AYFHS and national guidelines for the Integration of AYFHS into primary health care (PHC). Nigeria has chosen the approach of using the public sector PHC facilities for the promotion of the AYFHS agenda, as PHC is the level of care nearest to the population and the first point of contact with health services. With about 80% of the health facilities in Nigeria being primary health care facilities, and catering for the health needs of about 70% of the Nigerian population, integrating AYFHS into PHC has the potential for increasing its accessibility.
As evidence has shown nationally and globally, improved availability of AYFHS may not necessarily translate into improved outcomes, as the young people's utilization of services is often sub-optimal. The young people in Nigeria demonstrate poor health seeking behaviour due to a number of factors, including personal considerations, as well as health services and

The Concept of Access of Adolescents and Young People to Youth Friendly Health Services
In line with Nigeria's National Policy on Young People's Health and Development, adolescents refer to individuals within the age group of 10 to 19 years, while youth refers to those in the age bracket of 15 to 24 years (young people encompass both groups-10 to 24 years). Access, in a strict technical sense, involves the capacity to provide the needed health care, as well as .5 whether services are used effectively However, in a practical sense, access and the utilization of health services are often used interchangeably in the literature, with utilization considered as a proxy for access. In that context, the use of an available health service is seen as a marker for its accessibility. This is the approach used by the World Health Organization (WHO) in 6 defining standards for AYFHS and measuring coverage of adolescent HIV prevention and .7 sexual and re productive health services In line with the WHO's approach, accessibility means that young people (adolescents and youths) are aware of, and are able to obtain the health services that are available.

The Purpose of This Document
This document aims to provide programme planners, implementers and health managers at various levels with strategic considerations and broad guidance for actions needed to improve young people's demand for, and utilization of available adolescent and youth friendly health services. The overall goal is to improve young people's demand for, access to, and utilization of Introduction AYFHS in primary health care settings. This document complements the National

Guidelines for the Integration of Adolescent-and Youth-Friendly Services into Primary
Health Care Facilities in Nigeria, which aims at improving the availability of AYFHS.

Methodology for Developing this Document
The process of developing this document involved: • An appraisal of barriers to youth access of services at the PHC level • A review of the literature to identify best practices and models for mobilizing access to youth-friendly services in primary health care centres • Assessment of the models vis-a-vis the Nigerian health care environment • Technical dialogue among key stakeholders, as well as reviews from experts • Technical insight and inputs of the National Working Group on Adolescent Health and Development (representing a diverse group of experts and stakeholders on adolescent health in Nigeria)

Guiding Principles For Implementation
The following key principles underlie the approaches shared in this document.

Evidence-based ecological approach:
Adolescents are nested in the social context and, thus, their behaviour is not only individually determined, but highly-influenced by their social environment (figure 1). Thus, an ecological approach presents a sound theoretical model to mobilize young people for improved health services utilization, whereby not only the young people are targeted with interventions, but those with significant influence on their behaviour and gatekeepers.
2.1.2 Integrated, multichannel approach: These interventions and activities are designed to target barriers that exist at different levels within the social environment of young people, using diverse approaches that are expected to be synergistic. In this regard, an integrated multichannel approach will be used, whereby individual-targeted actions are complemented with broader focused interventions, using the mass media as well as community mobilization and advocacy strategies.

Focused, locally relevant and culturally-sensitive programming:
While the guidelines provide a general roadmap and generic actions, the implementation at every level and the detailed context of each intervention must be culturally-sensitive and guided by local traditions and situations, including existing socio-cultural barriers, health care situations and the result of the gap analysis, which indicates that there is a gap between the needs and desires of health care delivery for adolescents and the actual provision at the primary health care centres.

Rights-based approach:
Young people have an inalienable right to health services, protection, information, education and development opportunities. This document recognizes the rights of all young people, irrespective of gender, social class, ethnicity, religion, political belief, health status, sexual orientation, and other social and related factors to quality health services. As such, it recognizes that duty bearers have a responsibility to offer health services that are relevant to all young people without any discrimination.

Monitoring and Evaluation:
All programmes should be monitored closely and regularly and evaluated to ensure that they are implemented as designed, that needed adjustments are `made in a timely fashion, and that useful lessons are drawn for further applications and evidence-informed programming.

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Based on the ecological approach, two broad groups of interventions constitute the pillars of these strategic guidelines

Youth-focused interventions:
These embrace interventions that are primarily directed at young people so as to increase their demand for AYFHS. These activities broadly aim at improving young people's knowledge of, and motivation to use AYFHS, with the goal of engendering appropriate to improve their overall health and well young people (including the vulnerable and most-at-risk populations) must not be seen only as the end receivers of the services and interventions, but rather as active and essential players in every aspect and at every stage of the programme process. As such, they should be actively involved in the design, implementation, monitoring and evaluation of the interventions. Active participation by the end users is critical to the success of the interventions.
health-seeking behaviours being. The key ones are: in-school and out-of-school-based information, education and communication (IEC) programmes, peer education programmes and IEC outreach programmes to schools and communities.

Social environment-focused interventions:
These are interventions aimed at people who constitute the 'significant others' for young people, such as parents and guardians, teachers and community gatekeepers (including religious and community leaders). Interventions targeting the social environment would increase the community support for AYFHS, create an enabling environment for service delivery, and a supportive environment for adolescent and young people's uptake of services. These include: A. Community-based interventions B. Parental interventions C. Teacher-directed interventions. D. Sensitization via multimedia, including the social media

Specific Activities
Specific activities were designed to address various barriers limiting the access of young people to AYFHS, as well as promote utilization of services. The key ones include:

School-based Information, eucation and cmmunication (IEC) programmes:
These include the in-class implementation of the Family Life and HIV Education (FLHE) curriculum and other sexuality education curricula. Relevant co-curricular and extra-curricular educational activities for young people are important too. Also, the school may constitute a base for educating gatekeepers and the community, for example, through parent-teacher association.

Peer education:
Peer education can take place within the context of both in-school and outof-school youth. The in-school group has a rich potential to complement the in-school teacher-led sexual and reproductive health education. On the other hand, peer education provides a unique opportunity to reach the out-of-school youth who are more diverse in nature and more vulnerable in behaviour, and have not received adequate programmatic focus compared to their in-school peers. This strategy will also be extended to parents and guardians.

Community-based IEC activities:
Such activities can take place in a variety of settings within the community, including youth centres, town halls, markets and places of religious worship. They also include activities that take place during special, seasonal or episodic events that have a high attraction for young people, including community festivals and sporting activities.

IEC outreach from health facilities:
The staff of health facilities are expected to conduct IEC outreach exercises at nearby schools and communities on a regular basis. This can also be integrated into, or made to complement the school health services. These outreach programmes can be undertaken in the context of, or alongside medical screening for malaria, HIV, anaemia and other health conditions and facilitate early detection of diseases and appropriate referral.

Entertainment-educative approaches:
These are forms of communication that involve the use of the entertainment media to educate young people and their significant others, as well as foster the adoption of healthy behaviour and promote behaviour change. They include school drama, street and other community-based drama; road shows and rallies targeting groups of people to reinforce their awareness and knowledge, to clarify misconceptions, and facilitate the adoption of health-engendering behaviours to shape group norms positively. They also include the use of the electronic and/or print media-based drama and soap opera.

Mass media-based sensitization:
This includes the use of print materials, bill boards and electronic media (such as the use of radio talk shows and television documentaries), aimed at increasing awareness, building the knowledge base and influencing societal norms. Increasingly, the use of computer-based messages, mobile health platforms and social media are important in reaching young people with information and mobilizing them for healthrelated actions.

Community participation and social mobilization:
The aim is to sensitize community members, and get them to be actively-involved in the design, implementation and evaluation of activities aimed at supporting demand generation for AYFHS.

Advocacy:
Advocacy activities aim at influencing key stakeholders to embrace and support adolescent-and youth-friendly health services, as well as create a positive environment for AYFHS delivery and uptake. Other activities would include building the capacity and skills of young people in advocacy and/or lobbying.

Monitoring and evaluation:
Monitoring is required to ensure that programmes and activities stay on course, while evaluation helps to determine the success or otherwise of interventions and lessons for improved programming. Various approaches will be used in this respect, including supportive supervisory visits to programmes, periodic assessment of programme activities, review meetings and establishment of youth-provider feedback mechanisms.

Abraham, Sunday
Federal Ministry of Health (FMOH)

Addo, Samuel
Planned Parenthood Federation of America (PPFA) "Young people between the ages of 10 and 24 years constitute 33.6% of the country's population. This makes them integral to Nigeria's socio-political and economic development. Lack of adequate sexual and reproductive health information and services makes young people vulnerable to risky behaviours and negative health outcomes. This document is informed by the need to create awareness on available youth-friendly health services in the community, in line with the Action Plan for Advancing Young People's Health and Development in Nigeria".