The Elephant in the Room: Reducing Facility-Based Stigma and Discrimination Against Adolescents

One in every six people worldwide is an adolescent, which translates to 1.2 billion people between the ages of 10-19. While policies and programs for youth-friendly health services have significantly increased over the last decade, adolescents still face significant barriers when it comes to their health, particularly in low- and middle-income countries. Why do largely preventable poor health outcomes still exist? We know the answer to this question is complicated, and at RTI we are striving to address one of the many barriers that adolescents face in seeking care at health facilities: facility-based stigma and discrimination.

Adolescents who try to seek care at health facilities may be met with indifference, disrespect, and disregard. Frequently, healthcare workers assume that if adolescents visit a health facility for care, it is because they are engaging in irresponsible or dangerous behaviors (e.g., risky sex, drinking, drugs, or reckless activities that lead to injury). Facility staff can let their biases interfere with medical attention and may revert to scolding, shaming, or potentially intimidating the adolescent. While many programs focus on building adolescent-friendly health services, adolescents in many countries continue to face stigma when seeking services. That’s understandable—stigma is a challenging, complex issue that highlights the gray area where people’s personal beliefs and biases overlap with others’ rights.

Stigma and discrimination at the point of care is not unique to adolescents. However, it is particularly essential to address the stigma that adolescents face to ensure that they engage with the health system from an early age. Because adolescence is a unique development period—sexually, physically, socially, and emotionally—investing in adolescent healthcare yields a “triple dividend,” benefiting them now as adolescents, as adults, and into the next generation.

Adapting Time-Tested Tools to Address Adolescent Stigma

Through our longstanding work at RTI to improve quality adolescent health services, we noticed a gap at the facility level in tools that target the unique biases that adolescents face. To address this gap, we decided to adapt a participatory HIV stigma reduction training toolkit to be specific to adolescent stigma reduction. Developed under the USAID Health Policy Plus project, this HIV training toolkit was part of a total facility approach (TFA) to target HIV stigma and discrimination at all socioecological levels of a health facility. It was first successfully implemented in Ghana and Tanzania and since then, has been adapted and applied in Thailand under the USAID Inform Asia project.

We chose to apply the TFA to this work because it has shown that localized stigma reduction programming is successful. A key factor to the success of the TFA is that facilities own the entire process, which minimizes the role of outsiders and puts resources in the hands of local players.

To adapt and pilot the adolescent toolkit in Ghana, RTI partnered with the Educational Assessment Research Center (EARC), a local woman-led Ghanaian organization that we partnered with to develop the original HIV stigma reduction toolkit. EARC was at the center of the design of our project, so that the pilot facility’s first line of support was Ghanaian.  

One essential change we made to the existing toolkit was adding a training session on adolescent health that addresses the unique needs and challenges faced by adolescents. The adapted toolkit retained key components such as defining stigma and discrimination and education on gender and sexual diversity. It also creates awareness of what stigma is in concrete terms and supports participants to understand and address causes of stigma, build empathy, and work to create change.

Using the adapted toolkit, EARC held a Training of Facilitators workshop to introduce facilitators to the content and participatory training style. These facilitators then held workshops for the staff at the pilot hospital in Ghana. Facilitators included support, junior, and senior staff from the facility, some of whom were young adults and continued their efforts after the workshops as a champion team. The champion team is a group of leaders within the health facility that will carry the stigma reduction approaches forward after the initial training—an essential component of a total facility approach.

In our pilot hospital, the champion team used a small grant to determine and design their own response, which included producing stigma reduction messaging for the entire facility. This capacity strengthening method ensures that the skills, ownership, and enthusiasm are housed within the health facility, even after RTI or EARC leaves. This method also prioritizes culturally appropriate responses that meet the specific needs of that health facility.

Learnings from the Pilot in Ghana

We conducted a small evaluation to understand feasibility and acceptability of the training and stigma reduction materials. Our evaluation demonstrated that the pilot facility participants appreciated the training and the efforts of the champion team. They found the content informative and the delivery engaging, with some exceptions related to culturally sensitive and uncomfortable material about sexual and gender diversity. While participants expressed personal biases towards gay, lesbian, or transgender clients, by the end of the workshop, many expressed an understanding of why that should not influence how they treat these clients. This outcome, while suggesting we still have a long way to go, is promising. Until the most marginalized groups are welcomed into facilities with open arms, stigma and discrimination will always prevent adolescents from living fulfilling, healthy lives.

We also saw the benefit of involving all facility staff in the pilot. Traditional programs targeting youth-friendly services often focus on the medically trained health workforce—nurses, technicians, and doctors. Yet, adolescents also interact with non-health professionals at a health facility, such as the security guard or the intake receptionist. These interactions are equally important because an adolescent can easily be discouraged from seeking care when they arrive. The total facility approach recognizes the entire adolescent client experience from entry to exit. Under the pilot, security guards, cleaners, administrative staff, and management participated in the training alongside clinical staff, breaking down silos by building relationships between staff across departments.

[The trained staff] share their experiences at their various units, we are all not in the same departments, but they share their experiences with them. There was an instance when an adolescent girl came late when we had closed from work, then one staff shouted at her that didn't she know that it was late and she's now coming, when the other staff approached her and told her that she's an adolescent... so let's approach and ask why she's coming late, rather than we shouting at her, she might not come again. - Champion team interviewee

Participants enjoyed the engaging style of training; a panel discussion, role plays, and case studies helped participants engage fully with the content and better understand the adolescent experience. The training curriculum encouraged participants to self-reflect on their own experiences when they were adolescents; during our follow-up, they described how this helped them to build empathy with their young clients. Participants noted how the content influenced the way they do their jobs, and some even shared this new knowledge with family members. Without prompt, many participants shared specific attitude and behavior changes related to how they now treat adolescent patients, like no longer screaming at or insulting them, not using them for personal errands, and calling out other stigmatizing behaviors when they see them happen in real time.

Throughout the process, we saw the importance of localization, or putting the funds as close to the work as possible. EARC was involved in the design of the project from the beginning and contributed significantly to each adaptation of the toolkit. Their master trainers are incredibly skilled and through programs such as this, can transfer those skills to other local players. EARC now can lead trainings in both HIV and adolescent stigma reduction, validating the success of the step-down model of training in strengthening local capacity.

Putting an emphasis on localization also allowed for continuity in programming. We designed the original project with EARC at the center of the adaptation and pilot and RTI leading the evaluation component. The COVID-19 outbreak then made it impossible for RTI staff to travel to Ghana so we supported EARC to lead the evaluation activities with our virtual support. This full shift in ownership showcases the trajectory of how international development must proceed, increasing emphasis on local partners in the lead, developing leadership that represents the people it serves, and ultimately decolonizing global health.

[The worshop] has really helped us to know what to do for the adolescent... not neglecting them, not sacking them away, listening to them, give them a platform for them to express themselves. - Support staff, focus group discussion participant

Above all, participants did not let us forget that the health and livelihood of an adolescent is not solely affected by interactions at the health facility. Many participants wanted to know how this training would be utilized at the community level, in schools, or in other institutions where adolescents unfortunately experience stigma and discrimination. This connection is crucial—an adolescent’s health is often closely tied to their education or their economic opportunities. Perhaps adolescents still have unmet needs because we aren’t completely targeting stigma and discrimination in a comprehensive way.

Our toolkit provides facilities with an accepted and feasible approach to stigma reduction, but it doesn’t have to stop there. We found the material to be readily adaptable and it can be integrated into adolescent-friendly programming that goes beyond the walls of a health facility. If we expect our efforts to make a lasting impact tomorrow, we must dedicate attention and resources to fighting stigma and discrimination against the adolescents of today.