Amor Youth Clinic Network in Estonia

From the World Health Organization (WHO), this 56-page report explores the process of setting up a network of youth-friendly, free-of-charge sexual and reproductive health clinics in Estonia. In 2006, WHO's department of Child and Adolescent Health and Development (CAH) published a systematic review of the effectiveness of 12 interventions to improve the use of health services by adolescents in developing countries. CAH subsequently supported the documentation of 3 outstanding initiatives in different developing country settings - amongst them, this one from Estonia. As of late 2009, 18 "Amor" youth clinics in 14 counties had been set up to offer medical and psychological counselling (i.e. contraceptive counselling, sexually transmitted infection (STI) testing and management, HIV testing and counselling, pre-abortion and post-abortion counselling, gynaecological and urological examination, sexual counselling, psychological counselling and counselling after sexual violence), as well as sexual education lectures. In addition, telephone and online counselling are provided. Amor clinics serve men and women up to age 25.

As detailed here, an important development activity is the initiation of new clinics, which "requires a lot of time and energy. Therefore, an attempt is made to involve a wide circle of decision-makers and influential groups (media, local authorities)....New clinic workers are provided with the opportunity of gaining practical experience at one of the well-established and successful clinics. To help direct clinic work, workgroup members visit the clinic frequently before it opens as well as afterwards to discuss with the staff members various issues regarding their actual work and organizational matters."

Lessons learned from creating and developing a youth clinic network:

• Good ideas should be boldly expressed, even if at first they seem unrealisable.
• It is necessary to define precisely both the objectives and the means and rules for achieving them even in an unofficial association formed by enthusiasts. This ensures that the process is democratic and is necessary both for further development and to receive further funding.
• Visits to other countries and visits by lecturers from them can give further impetus and inspiration for improving the local situation. At the same time, all good examples cannot be implemented without considering the local circumstances.
• It is important to cooperate with key local figures and organisations, and not to rely only on foreign professionals and donors, to achieve further support and sustainability for the youth clinics.

As detailed here, many young people obtain information from the Amor website as well as from new printed matter compiled every year, such as posters and flyers, appearances on television and radio, and articles published in newspapers and magazines. In addition, organisers attempt to participate in national and local youth-oriented events to distribute information in cooperation with other youth organisations and institutions.

Over the years, gathering statistics and obtaining other feedback has been an important part of Amor's work. Regular surveys are conducted to assess young people's satisfaction with service provision, and, since 2003, young people have been invited to continually provide feedback online. Furthermore, youth clinics give an activity report to the Estonian Sexual Health Association (ESHA) every quarter, and the statistical indicators that are compiled give the workgroup a chance to analyse each clinic's activities. Each clinic receives feedback in which its actual activities are compared with those projected, those of other clinics, and the project objectives.

Lessons learned from providing services:

• A distinctive feature of youth clinics in comparison to traditional health systems is their use of integrated medical and psychological counselling services.
• Services must be accessible and adapted to the needs of young people: provide services free-of-charge, make available specific written information materials, maintain short waiting lists, and keep separate youth-friendly rooms. It is important that a youth counsellor is always "on the same wavelength" as the young person; judgmental and condescending attitudes generate distrust and fear.
• Equal emphasis must be placed on medical and psychological counselling and sexual education lectures. By attending lectures, young people get used to the clinic and are apparently more willing to come for a personal visit when needed.
• Young men in Estonia visit youth clinics less often than do young women. This must be taken into consideration while planning a clinic, advertising the service, training the staff members, and setting up the function of rooms.
• Young people are as diverse as their needs and not all may be able or ready to visit a clinic. It is beneficial, if the opportunity exists, to offer them alternative sexual health information and counselling options, such as through telephone and online counselling.
• The creation of new services or networks for young people should begin with ideas of how to clearly differentiate youth clinics from other similar organisations. An understandable name together with a clearly distinctive image helps gain popularity among young people.

Lessons learned from the expansion of activities:

• The development of each of the clinics, as well as the entire network, stems in large part from a grassroots concern that has greatly helped in the realisation of many good ideas. In addition, it is important to have written working principles and to ensure that all network members abide by them.
• More important than identifying funding is finding the right, dedicated people for the job. The main feature of youth clinics is the people who are motivated and love their job. This fact, together with an ongoing training system and in view of the needs of the youth clinics and their continuity, plays an important role in promoting quality of care.
• Constructive and regular feedback from all (clinics to the ESHA, young people to the ESHA and clinics, workgroup to clinics, funders to the ESHA and clinics) has been an important part of the ongoing learning process of the network.
• Regular financing, both for services and development actions, allows for the sustainability of services and ensures the continuous promotion of quality.

Selected results of evaluations, 2002-2006:

• The number of visitors to youth clinics has been increasing every year, and the proportion of first-time visits has increased yearly. The majority of the clients are female university students. Though the total number of male visitors has increased, as a proportion the goal has not been achieved. With an increase in the total number of visitors each year, the goal of 10% young male clients is difficult to achieve - particularly due to the limited visiting hours and number of staff members trained to deal with young males.
• The number of lectures and participants has remained stable over the years despite not being regularly funded. A relatively large part of youth counsellors' time is spent on telephone counselling which has grown in volume over the years, except in 2006.
• The number of STI tests at youth clinics has increased over the past 5 years (as has the number of prevention cases), and the number of detected cases of STIs has decreased. Youth clinics in Estonia diagnose approximately 30% of new cases of chlamydia and trichomoniasis, 15-30% of new cases of gonorrhoea, but only approximately 1% of new HIV cases. The low HIV-detection rate at youth clinics (since Estonia has a very high rate of HIV infection) may be because the spread of HIV began among injecting drug users (IDUs), who as a rule do not acknowledge their need for help and therefore are not voluntary (youth clinic) visitors.
• Surveys show that satisfaction with services has constantly been over 90%. In general, clinic visitors are satisfied with the accessibility of services - for instance, reception is fast and uncomplicated. Visits to clinics are a positive experience, as clients receive information that is not available at the school or home and find solutions to their problems. The qualities most valued in clinic staff members were their friendliness and professionalism. Younger clinic visitors were more critical of and sensitive to the personal traits of staff members while older visitors were generally satisfied with clinic staff members. Respondents were least satisfied with the access to clinics by telephone, long waiting lists at some clinics, and visiting hours that are unsuitable for young people and too short. Remarks were also made about limited space, and the fact that intimate discussions taking place in the counselling room could be heard in the waiting room.
• From 2003 to the end of 2006, 1,280 young people gave feedback online, of whom 95% rated the activities of the clinic as "good" or "very good". Online respondents are most satisfied with the clinic staff members - in particular, with their personal traits (friendliness, readiness to help, empathy), professionalism (ability to communicate, advise, and explain) and their attitudes towards young people (tolerant, nonjudgmental). Visitors also value the clinics' organisation (free services, short waiting lists in comparison to other options, telephone counselling). Young people added that they trust the clinic staff members and that clinics provide sufficient privacy and security. Negative feedback has mostly been concerned with the lack of information regarding the youth clinics and the shortage of clinics and staff members. There have been complaints that clinics do not advertise themselves enough, that waiting times are too long, and that sometimes appointment times are behind schedule.
  

In addition to the above, youth counsellors from 11 clinics and most of the workgroup members carried out a self-assessment of clinics and the clinic network during a summer training session in 2006. In brief, although the greatest strength was identified as "the motivated staff members in the clinics, the coordinating workgroup and the ESHA", one of the weaknesses of the clinic network identified was the shortage of suitable staff members in specific fields (e.g. Russian-speaking and English-speaking counsellors, counsellors for young males, and psychologists) and insufficient recruitment of new staff members. Thus, "To provide a more versatile service for young people, one possibility is to engage, as youth counsellors, social workers and psychologists who have completed supplementary training (youth counsellor basic training course) and to expand counselling for young males. More information sessions could be organized at the clinics or short-term training courses for associated specialists (e.g. social workers, human studies teachers, school health workers) and a series of lectures could be developed for health care and social programmes at institutions of higher education. Widening of the clinic network to districts where either no corresponding service is available or limited service is offered is an important challenge and opportunity."