1 Introduction

Adolescence and youth mark a transitional phase between childhood and adulthood, according to the WHO, encompassing ages 10–24. This period, characterized by physiological, psychological, and social changes, exposes young individuals to risky behaviors, including early sexual experimentation and substance use [1, 2]. By 2015, the global youth population reached 1.2 billion, comprising one-sixth of the world′s population. In Africa, 226 million youths accounted for 19% of the global youth demographic. In Ethiopia, approximately 21 million individuals aged 10–24 represented about 33% of the total population. Among these, 10–14-year-olds constituted 15.6%, 15–19-year-olds 10.6%, and 20–24-year-olds 7.6% [3-5]. Despite being generally considered healthy, young people face higher risks of sexual and reproductive health (SRH) issues, premature death, and illnesses such as STIs and HIV/AIDS. Unhealthy behaviors like alcohol and tobacco use, along with exposure to violence, contribute significantly to these risks, impacting not only their current health but also their future well-being and that of potential offspring [5, 6].

Globally, over 1.5 million adolescents and youths aged 10–24 died in 2019 due to preventable or treatable causes, highlighting the persistent gap in accessing SRH services. Despite demonstrated needs, young people often face underserved healthcare, resulting in significant health and related issues such as early marriage, unwanted pregnancy, incomplete education, and the threat of sexually transmitted infections (STIs), including HIV/AIDS [7, 8]. Addressing the health needs of this vulnerable demographic requires quality health services that support their transition into adulthood. The WHO advocates for Youth-Friendly Services (YFS) designed to be accessible, equitable, and effective, aiming to mitigate SRH problems and increase overall service utilization among young people [1, 9]. WHO defines quality of care as ensuring healthcare services improve desired health outcomes, emphasizing safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness [10]. Donabedian argued that providing quality healthcare would minimize risks and maximize the benefits of medical services. According to Donabedian, quality assessment in healthcare aims to evaluate whether programs have the right inputs, implement the correct processes, and achieve desired outcomes [10, 11]. Healthcare quality can be assessed based on three main domains, namely: Structure, process, and outcome. According to Donabedian, structure refers to the characteristics of the health facility in which care is delivered and accessed. Examples are: Amenities, equipment, human resources, and organizational structures. Structure may also include health providers ′skills, operating hours of the facility, and convenience in scheduling appointments. Donabedian defined Process as—what is actually done in the giving and receiving of healthcare. He classified the process into clinical and interpersonal processes. Clinical process refers to the clinical guidelines and standards that must be observed by health providers. The interpersonal process refers to the interaction between the patient and the provider. Donabedian argued that there is a relationship between structure, process, and outcome. He emphasized that quality assessment is possible only because good structure increases the likelihood of good process, and good process increases the likelihood of good outcome. Structure and process can influence outcome, either directly or indirectly [10, 11].

In Ethiopia, efforts to address the SRH needs of adolescents and youths began with the development of the first adolescent and youth strategic plan in 2007–2015. Subsequent initiatives, like the establishment of YFS in 2009, aimed to reduce barriers to healthcare by adopting multi-level service delivery approaches. However, challenges persist, prompting the implementation of the third National Adolescent and Youth Health Strategy (2021–2025) with a focus on scaling up services across all healthcare facilities [12-16]. Despite governmental efforts, YFS services in Ethiopia struggle with low utilization among adolescents and youth, hindered by challenges related to the sensitive nature of sexual health and perceptions of healthcare delivery models. Young individuals often lack the information, experience, and comfort to access reproductive health services compared to adults. Studies reveal substandard quality in Southern Ethiopia′s public health facilities, the quality of adolescent and youth-friendly health services (AYFHS) in public health facilities was below standards which was 54.4%, 42.0%, and 49.1% for structural, process, and output quality dimensions, respectively [16-20].

The Ethiopian Demographic and Health Survey 2016 revealed a 0.3% HIV prevalence among 15–24-year-olds and a mere 14% utilization of family planning services, contributing to high rates of unwanted pregnancies and unsafe abortions. In addition, the country faces a significant prevalence of STIs, with approximately 2.5% of women and 3.6% of men aged 15–19 reporting symptoms such as genital discharge or sores [21]. In the Amhara region, AYFHS fell below the standard, with quality dimensions measuring at 58.8%, 46.4%, and 47.2% for structural, process, and output quality, respectively. Unemployment, payment for services, lack of personal income, and service waiting times emerged as predictor variables affecting client satisfaction with output quality [20].

Both high and low-income countries suffer from uneven YFS quality, with lower-income nations experiencing compromised health intervention impact due to poor care quality. In Ethiopia, particularly in the study area, there′s limited evidence on the quality of YFS, with existing literature mainly addressing factors influencing AYFHS utilization [7, 17, 22-24]. Hence, the objective of this study was to assess the prevalence of the quality of YFS and identify the associated factors in the public health facilities of the Awi Zone in Northwest Ethiopia, 2023.

2 Methods

3 Results

4 Output Related Quality of Health Facilities

Only two health facilities demonstrated good quality in output performance, while five had medium performance and three had low performance. None of the health facilities reported client satisfaction with psychosocial assessments or satisfaction with information provided on risk reduction and prevention.

Consequently, the overall level of client satisfaction toward AYFHS in Awi zone public health facilities was 44.6%, with a 95% confidence interval (CI) ranging from 40.7% to 48.5%. Specifically, 45.3% of males and 43.9% of females expressed satisfaction with the services provided at AYFHS units. The satisfaction levels among the age groups of 10–24, 15–19, and 20–24 were 33.3%, 42.4%, and 49.8%, respectively. Below is the table presenting the items and results of the process-related quality assessment (Table 4).

5 Discussion

This study evaluated the quality of AYFHS in public health facilities within the Awi zone using the Donabedian Quality Assessment Framework. The findings indicate that the overall quality of AYFHS in these facilities falls below the established threshold of 75%. This outcome aligns with quality assessment findings from other regions, including southern Ethiopia, Sendafa in the Oromia Region, and western Gojam, all of which similarly reported AYFHS quality as “not good quality” [4, 17, 28].

While health facilities demonstrated a good quality score in the input component, it does not align with the WHO AYFHS standard criteria for service accessibility and acceptability. This discrepancy may stem from resource constraints and competing health priorities within the study area. For instance, each health facility was only allocated one trained AYFHS provider, likely due to insufficient budgetary provisions for training additional healthcare providers. Consequently, the delivery of services to beneficiaries fell short of requirements. These findings echo those of studies conducted in public health institutions in Dahana and West Gojam districts of Ethiopia, highlighting the lack of training among health workers as a significant issue. Moreover, the study revealed that AYFHS was unavailable at all medical facilities on weekends and during late afternoons. Given that a majority of beneficiaries were students, overlapping working hours with school hours can pose challenges for young people seeking medical care. This finding resonates with similar studies conducted in the Sendafa districts and Ghana [10, 20, 23, 28].

None of the healthcare institutions incorporate adolescents and youths in their governance structures or in the planning, monitoring, and evaluation of health service delivery. Consequently, this exclusion may hinder the ability of medical services to effectively address the needs of young people. This pattern aligns with findings from a study in the Dahana district, where youth participation in healthcare governance structures was also lacking. Our study further revealed that all health facilities in the district lacked policies, protocols, and SOPs for implementing AYFHS, as these materials were not provided by the district health department. The absence of such policies, protocols, SOPs, and adequate AYFHS training can significantly impact the quality of service delivery. This discovery is consistent with prior research indicating a dearth of AYFHS policies, procedures, and protocols in most facilities [20, 22].

The process quality emerges as the most compromised aspect among the two quality components assessed. This decline in process quality may stem from the insufficient training of providers delivering AYFHS in the study area. Despite the presence of trained providers in all health facilities, many adhered to conventional practices rather than implementing specialized AYFHS protocols. Treatment was often provided solely based on client complaints, without addressing broader health concerns. In addition, providers expressed dissatisfaction with their work in the YFS room. Furthermore, the client-provider interaction analysis revealed that none of the health facilities ensured auditory and visual privacy for clients. These findings mirror those of a study conducted in West Gojam Zone, indicating a lack of utilization of audio-visual materials specifically tailored for SRH services [28].

The study′s findings revealed that the main factors contributing to poor privacy were the inconvenient physical setup, with most facilities located adjacent to other outpatient departments, frequent interruptions during consultations, and leaving doors open. These findings suggest that without adequate privacy, clients may be reluctant to discuss sensitive issues or may feel inhibited in disclosing concerns related to SRH [29].

Moreover, the absence of privacy can impact user satisfaction, their likelihood to recommend the service to others, and may deter them from returning for further assistance. In addition, the quality of service delivery was notably influenced by AYFHS providers′ failure to establish rapport with clients (such as by introducing themselves) and utilize audiovisual aids. This discovery aligns with findings from comparable studies conducted in Ethiopia [17, 28, 30].

Furthermore, only four health facilities offered information on institutional resource availability, while risk reduction and preventive interventions were implemented in three health facilities. In addition, the assessment of psychosocial history was inadequately conducted in only four health facilities. These findings are in line with a study conducted in the West Gojam and Dahana districts of Ethiopia, which also noted insufficient information on psychosocial assessments and available services for young people [20, 28].

Moreover, the overall client satisfaction rate with AYFHS was recorded at 44.6%. This finding is consistent with similar studies conducted in Dehana district and Arbaminch city in Ethiopia, which reported satisfaction rates of 47.2% and 49.1%, respectively. However, it falls below the satisfaction rates observed in studies conducted in South Africa (81.7%) [31], Sendafa Oromia region (70.3%) [4], and Dessie town (58.9%) [27]. Possible explanations for this variation include differences in the quality of service delivery, subjective measures of satisfaction, and the expectations of AYFHS clients [17, 20].

Client age was found to be significantly associated with AYFHS client satisfaction, with those in the 15–19 year age group being 32% less likely to report satisfaction compared to those in the 20–24 year age group. This finding aligns with studies conducted in Mongolia and the Sendafa Oromia region, where lower levels of satisfaction were observed among younger adolescents. This decrease in satisfaction among younger adolescents could be attributed to feelings of shame and fear in seeking services they need, as they may be less exposed to reproductive health-related issues and thus more dissatisfied. Conversely, a study conducted in southern Ethiopia showed that the 15–19 age group was more likely to be satisfied with AYFHS compared to those in the 20–24 year age group. This difference may be explained by the fact that older adolescents typically have increased health concerns, greater understanding and cognitive skills, and are more likely to develop their own independent views about their social environment [4, 17, 32].

Another significant predictor was the payment status of clients. The study revealed that clients who received AYFHS for free were more likely to report satisfaction compared to those who paid for the services. This finding aligns with research conducted in the West Amhara region, Ethiopia, suggesting that financial constraints and high medical costs may hinder adolescents and youths from accessing satisfactory AYFHS. In addition, clients who waited less than 30 min for service were twice as likely to report satisfaction compared to those who waited over an hour. This finding is consistent with similar studies conducted in southern Ethiopia and the West Amhara region. The longer wait times may be attributed to high client volumes and inadequate deployment of AYFHS providers in Awi Zone public health facilities. It may also reflect a lack of awareness among service users regarding the time required to deliver quality healthcare services [17, 33].

Another significant predictor variable in this study was the time of arrival at the health facility. Findings indicated that clients residing within a 30-min walking distance from a health facility were 1.60 times more likely to report satisfaction compared to those with over an hour′s journey on foot. This finding aligns with research conducted in Tehuledere, Northeast Ethiopia, suggesting that the relatively short distance may contribute to client satisfaction by minimizing travel discomfort and facilitating a prompt return home [34].

Furthermore, qualitative analysis revealed common challenges voiced by participants, including concerns about payment for services, staff turnover, and the burden of client/patient load. Almost unanimously, participants highlighted the need for charge-free services and suggested extending service hours to include weekends [28, 35].

6 Strength and Limitation of the Study

The study demonstrated strength by comprehensively assessing quality dimensions following the Donabedian model. Employing various approaches for different objectives enhanced the study′s robustness. In addition, the exclusion of the first three client-provider interaction observations mitigated the Hawthorne effect. However, the cross-sectional design limited the ability to establish causal relationships between dependent and independent variables. Furthermore, the study focused solely on adolescents and youths at healthcare facilities, overlooking those within communities. Future research endeavors should contemplate the inclusion of these populations for a more holistic understanding.

7 Conclusion and Recommendation

The study findings indicate that the overall quality of YFHS falls below WHO standards across its structural, process, and output components. Performance indicators vary from low to medium, particularly highlighting deficiencies in elements pertinent to adolescents. Structural quality is compromised by a shortage of well-trained health personnel and limited adolescent engagement in care. Moreover, the absence of policies, protocols, and guidelines further hampers structural quality. Process quality suffers from inadequate assurance of client privacy and confidentiality, lack of efforts to establish rapport with clients by providers, absence of audiovisual aids, and subpar assessment of psychosocial histories. These findings underscore the inadequacy of the current YFS approach in addressing evolving client needs and in prioritizing SRH services at healthcare facilities. In addition, the study identifies age, travel time to healthcare facilities, waiting time at facilities, and payment for services as independent predictors of client satisfaction with youth-friendly health services.

The study emphasizes the urgent need to enhance the quality of youth-friendly health services (AYFHS) in health facilities, which currently do not meet established standards. To achieve this, health facilities should actively engage adolescents and youths in governance structures to facilitate planning, implementation, and monitoring. Healthcare providers must strictly adhere to national guidelines, ensuring privacy, confidentiality, and comprehensive attention to consultation times and psychosocial assessments, along with providing accurate information on risk reduction and prevention. Regional health bureaus and district health departments should formulate and disseminate crucial policies, protocols, and guidelines for AYFHS implementation. In addition, to reduce long client waiting times, healthcare facilities need to ensure adequate staffing and training of providers assigned to AYFHS rooms.

Author Contributions

Gashaw Alamineh: conceptualization, investigation, writing – original draft, methodology, writing – review and editing, software, data curation, formal analysis, visualization, project administration. Alemtsehay Mekonnen Munae: writing – original draft, methodology, validation, writing – review and editing, software, supervision, conceptualization. Melash Belachew Asiresie: conceptualization, writing – original draft, methodology, validation, writing – review and editing, software, supervision. Mekonen Melkie Bizuneh: conceptualization, writing – original draft, writing – review and editing, software, methodology. Zemenu Shiferaw Yadita: conceptualization, writing – original draft, methodology, validation, writing – review and editing, software, supervision.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Zemenu Shiferaw Yadit,a affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.