Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694824186564.pdf (Georgia)
Survey on Youth Friendly Reproductive Health Services in Georgia 2007 RHIYC Office 28, Abashidze street, Tbilisi, Georgia, 0179 Tel/fax (+995 32) 231 977 www.foryouth.ge www.4uth.ge www.4uth.net www.unfpa.org.tr/georgia Reproductive Health Initiative for Youth in the South Caucasus Survey on Youth Friendly Reproductive Health Services in Georgia Survey is conducted by Gorbi-Gellap International Centre Tbilisi 2007 The survey has been prepared in the frame of EU/UNFPA Co-funded project “Reproductive Health Initiative for Youth in the South Caucasus” The content of this publication are the sole responsibility of the authors and can be in no way taken as to reflect the views of the European Union and UNFPA ISBN 978-9941-0-0872-6 Table of Contents Introduction ...........................................................................................................................2 Methodology .........................................................................................................................4 Survey results .......................................................................................................................6 1.
Accessibility to reproductive health services....................................................................6 1.1.

Physical availability of the RH/SH services...............................................................6 1.2.

Financial availability of RH/SH services..................................................................10 2.

The informative-educational possibilities for youth in RH/SH services ..........................13 3.
The quality of care in RH/SH services ...........................................................................14 3.1.

Compliance of medical facilities and medical personnel with the standards ..........14 3.2.

Confidentiality and privacy in RH/SH services ........................................................18 3.3 RH/SH service Medical personnel’s attitude towards young patients ......................22 3.4.
Quality of medical service and consultations in RH/SH services ............................25 4.
Assessment of the quality of medical services and consultations on the basis of scenarios ...................................................................................................................30 Scenario 1 .....................................................................................................................30 Scenario 2 .....................................................................................................................31 Scenario 3 .....................................................................................................................33 Scenario 4 .....................................................................................................................34 Scenario 5 .....................................................................................................................35 Summary of results of the survey carried out according to the scenaios ............................36 Summary ............................................................................................................................................37 Recomendations .................................................................................................................40 References.........................................................................................................................................41 Appendix 1 ..........................................................................................................................42 Appendix 2 ..........................................................................................................................48 11 Introduction According to the most recent data the youth (10-24 age group) make up the majority of the world’s population – 1.5 billion.
In Georgia, young people of this age constitute 25% of the total population.

These are the formative years where youth are first introduced to their sexuality.

Many Georgian youth are becoming increasingly sexually active.

Regardless, the decision to be engaged in sexual relations becomes more and more obvious as indicated by the number of unplanned or adolescent pregnancies and complications related to abortions.
There is also increased risks and difficulties connected with teenage child birth and related emotional problems for young parents, problems of sexually transmitted diseases (STD), which not only includes common venereal diseases but the ever present of contracting the deadly HIV/AIDS virus.
Despite on-going reforms in healthcare sector and improvement of specific health indicators there are still various problem areas connected with reduction of public financing of health care, affecting the RH/SH Services as well.

public health has been impacted a reductions in funding, which has also impacted.

Solution of these problems is essential taking into consideration current demographic crisis facing Georgia (more deaths than births).
The problem is further complicated by acute socio-economic conditions that prevent women from being able to access and afford an adequate level of health care.

The latest study1 showed that more than half of women (58.9%) can’t afford medical care because of various economic restraints.

25 percent of the population in Georgia consists of young people.

The survey demonstrated that the highest birth rate was found among females that are between the ages of 20-24.
More then half of live births were reported among females in the 15-24 years-of-age1.

The mean age for marriage (21.6) and the average age of beginning sexual activity (21.3) among females are almost the same.

Whereas the mean age for marriage among males stands at 25.1 years of age, which is significantly high when compared to the mean age for their first sexual intercourse (17.5 years-of-age).
These findings demonstrate that there is still a high risk of pregnancy and STDs, which is largely attributed to sexual intercourses among unmarried youth, and because precautions were not properly used, if applied at all.

The surveys conducted in 1999 and 2005 showed that the abortion rate among 15-19 years old females had significantly been reduced (by twice and more).

Among 20-24 years old females this indicator has not significantly decreased (162 and 126 accordingly) and it still remains high.
The findings about the usage of contraceptives demonstrate that their overall use has increased in recent years (40.5% - 1999 and 47.3% - 2005)1,2, and this is especially the case with the use of modern birth control methods.

However, the increase is not enough.

It needs to be mentioned that this indicator among 15-19 years old females is approximately 13%, and among 20-24 years old females stands at 37.7%.
It’s alarming that that the tendency to have consultations about using contraceptives and prescribing contraception methods and their proper use after a woman has undergone an abortion drops to a very low level1 (21.8% and 6.3% accordingly) that indicates inefficient activities of health professionals.
It appears that these indicators vary by age groups, and there is a tendency to give less information to patients about various birth control methods as they are older, which may be predicated on the assumption that a woman that is in the age of 20-24 is more knowledgeable about various methods than a 15 to 19 year old.

The exchange of information may be even further reduced as the patient increases in age.
Moreover, this tendency indicates that 1 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 2005 2 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 1999 2 2 doctors are not working to a high professional standard, and are not skilled in communication with patients in addressing the full range of patient needs.
The majority of youth considers that they are in need of more information about their options and they need to have an adequate level of knowledge and information about the different kinds of contraceptive methods and RH/SH services available to them1,2.Young females and teenagers consider that the best source of information about RH/SH services continue to be specialist doctors1,3.
However, among 15-19 and 20-24 years old females only 1.7% and 5.4% accordingly have received the information about the above mentioned topics, STDs and HIV/AIDS from healthcare workers.

An undesirable tendency was found while comparing the findings obtained in 2005 and 1999 of gynecological examinations and PRENATAL visits of young females.
The results show that the rates have been slightly reduced1,2.Nonetheless, the rate of stillbirths (16/1000 deliveries) and infant mortality still remains high (29/1000 live births).

STDs are fast becoming a serious problem for all ages in Georgia, especially for young people.

They are not fully aware of the risks involved in unprotected sex and the potential complications that they may experience in their futures.
The lack of knowledge and access to accurate and up-to-date information about reproductive health and sexual well-being creates many problems.

Lack of accessibility is also conditioned by social and psychological barriers.

The overall reproductive and sexual health of this target group is determined by a number of factors: poor accessibility to reproductive health services due to financial and physical factors of potential clients in being able to access services.
Youth are limited in the ability to access information.

Often the only ways of getting the information about available RH/SH services are close peers and larger networks of friends who may have had some experience with the system that they can share.

Young people are generally distrustful towards the providers of medical services and visit them only in case of emergencies.
On the basis of discussions carried out in 2001-2002 the World Health Organization has developed those basic requirements that should be met by youth friendly RH/SH services: Favorable policy, which implies protection of their rights based on corresponding UN declarations and protocols and other documents.
These have placed emphases on such issues as gender problems, maintaining privacy and keeping confidentiality, ensuring autonomy that will enable young people to make their own consent for treatment, They should also have either free or discounted access to reproductive health services.
Youth friendly procedures including simplification of patient registration in order to assure confidentiality, which includes assumption that puts patient rights and privacy in the forefront in the storing and retrieval of medical histories.

Waiting times should be minimized and medical procedures should be performed in a timely manner.

In addition, registration, setting dates for appointments, and waiting times should be reduced as much as possible.
Alternatively, it should be possible to obtain consultations without the requirement of preliminary registration.

1 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 2005 2 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 1999 3 mozardTa reproduqciuli janmrTelobis kvleva UNFPA.Tbilisi 2002 3 3 Youth friendly personnel, qualified in reproductive health issues.
Those who are delivering such services aimed at prevention, treatment and care, must also have good communication skills and able to adapt the delivery of services to the social conditions of each patient.

They should not communicate in a disapproving or judgmental manner.

They should be motivated and have the ability to provide young patients with the necessary information as may be required.
However, currently there is no defined list of operational standards of best practice that should be met by youth friendly services in various counties.

Although, there should be some guidelines in place as a template for best practice, and this must be formed in consideration of unique cultural- traditional, economical, social, geographical and health service peculiarities of a given country.
It is recommended to distinguish the factors that must be addressed by RH/SH services in various countries for the effective planning and implementation of measures necessary for the creation youth friendly centers.

Study of RH/SH1,2,3,4 in Georgia revealed low level of knowledge among the youth despite their good awareness in various RH/SH issues, poor utilization of RH/SH services, inadequate level of medical treatment and consultations in RH/SH services.
The difficulties encountered in the physical and financial accessibility of RH/SH services among youth remains to be an obstacle for improvement of their sexual and reproductive health.
Therefore, establishment of youth friendly RH/SH services in Georgia will help this age group gain greater access to medical personnel and will further increase their knowledge in this field, which should include giving the information about the disadvantages of abortions, learning about the modern methods of family planning, understanding how STDs and HIV/AIDS are spread, and being able to take appropriate preventive measures, identifying the early symptoms of curable STDs and understanding the importance of following full treatment course.
It is essential that responsible reproductive and sexual behavior be practiced at an early age, which is the basis of prevention of infertility and improvement of health in the future.

Establishment of youth friendly RH/SH services in Georgia will also help in assuring teenagers in the positive sides of participation in preventive screenings and will help them to get into the habit of annual check ups, which will result in improvement of health status of general population.
Youth friendly RH/SH services can also make a great contribution in intensive PRENATAL treatment and care for young females and provide them appropriate conditions to access normal pregnancy checkups and to prevent possible complications, thus reducing overall maternal and child mortality.

In order to specify the actions aimed at establishment of youth friendly RH/SH services and ways of their implementation it is highly recommended to conduct preliminary survey for studying the existing situation.
The purpose of such a survey would be to provide significant basis for the implementation of an appropriately targeted strategy for the development of youth friendly RH/SH services that would lead to the overall improvement of youth RH/SH health.
Such a plan should take into full consideration RH/SH rights and it will further reinforce the overall aims of human development, 1 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 2005 2 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 1999 3 mozardTa reproduqciuli janmrTelobis kvleva UNFPA.Tbilisi 2002 4 mamakacTa reproduqciuli janmrTelobis kvleva UNFPA.Tbilisi 2005 4 4 Methodology The actual fieldwork for this research was conducted between the 8th and 11th of October 2007.
The survey was conducted in the following regions of Georgia: in Tbilisi - 74 interviews, Imereti – 20 interviews, Adjara – 17 interviews, Samegrelo – 15 interviews, Kvemo Kartli – 10 interviews, Shida Kartli – 5 interviews, Kakheti 9 interviews and for the Mtskheta-Mtianeti region – 3 interviews.

 The methodology of interview – “mystery user”.

 The number of interviews taken - 151.


 In the field research participated 19 interviewers under 20 years old, among them 5 were males and 14 females.

 The questionnaire was prepared by GORBI-GALLUP International Association.
Besides the assessments that are based on information obtained from the questionnaire (physical and financial accessibility of RH/SH services, confidentiality and privacy) five different scenarios have been developed in order to determine the quality and adequacy of medical care and consultations.

Specially trained interviewers visited RH/SH services according to these scenarios and applied different above-mentioned scenarios.
After the visit the interviewers were answering specific questions that were especially prepared for each of scenarios (appendix #2).

 A five point grading scale was used in assessing the quality of medical care at RH/SH services.

5 points corresponded with “very good”, 4 points - “good”, 3 points - “medium”, 2 points - “bad”, 1 point -“very bad” .
The points system was reflective of a percentage indicator score: 5 points – 80-100%, 4 points – 60-79%, 3 points – 40-59%, 2 points – 20- 39%, 1 point – 1-19%.

 The data were processed in SPSS, analyzed at the main office of GORBI-GALLUP international center.

5 5 Survey results 1.

Accessibility to reproductive health services.

1.1 Physical accessibility to the RH/SH services.


Physical accessibility to RH/SH services is very important for young patients, who may be visiting this kind of facility for the first time.

The respondents were asked several questions for assessment of the physical accessibility to RH/SH services for youth in Georgia.

It was identified that majority of youth (78%) could easily find the above-mentioned facilities, which was practically the same between females and males (77.9% vs. 80.6%).
It has been expected that males would have experienced more difficulties in finding these locations, as females are more informed in RH/SH spheres, and they are traditional and well- known services for them (women’s consultation center and other reproductive health facilities).

Meanwhile until now males receive such RH/SH services in such medical facilities that don’t match with patient’s needs.
We may assume that young man more often and easier use the experience of their friends in solving these types of problems.

In terms of physical availability to RH/SH services significant differences were displayed between towns and villages.

It was twice as difficult for young people (40.0%) to find out the location of such services in villages compared to towns (81.1%).

Those that were the most accessible were in Tbilisi (85.1%), and in other towns (76.8%).
The differences were also displayed according to the regions.

These services were more available in Mtskheta-Mtianeti (100%) and Imereti (95.0%) regions, and the least often in the Shida Kartli (40%) and Kakheti regions (22.2%).

Diagram1 Distribution of RH/SH services by locations (%) ?

No 22% Did you find the reproductive health cabinet to be conveniently located?
100 90 80 70 60 50 40 30 20 10 0 Yes 78% 15 i s i l i b T % 85 93 73 71 80 78 100 60 40 27 20 22 o m e v K i l t r a K i t e h k a K o l e r g e m a S - a t e h k s t M i t e n a i t M i l t r a K a d i h S 1 1 29 a r a j d A 6 i t e r e m I Yes No As the distribution shows hospitals (96%) and private gynecological clinics (90.9%) are easily found.

And based on the type of medical service provided, the tendency exists that when the reproductive clinic is in a hospital it is the easiest to find.
However, it is more difficult to make 20 6 comparisons when discussing accessibility of private gynecological clinics.

Such kinds of facilities are probably less reliable, thought it is possible, that according to specific youth related psychological difference that this age group is better able to turn to this type of facility more often with their problems than others.
Sings and written instructions on the front side of medical buildings and at or near the entrance of various departments make accessibility to RH/SH services easier.

The survey identified that there were sign boards posted at the various facilities in the vast majority of instances (81.7%).

These could be found on the front side of the facility’s building.

However, illuminated signs were the rare exception.

These were found only in 7.8% of instances.


No signs on the fronts of building were found in 10.5% of visits.

However, in comparison, illuminated signs were found only among female RH/SH service providing facilities.

Presence of common signs on the facilities fronts was a rather frequent in Tbilisi and other towns (85.1% and 82.6% respectively).

However, when compared with villages, this proved to be the case in only 50% of cases.
There were not any significant differences noted between regions (70%), with the sole exception of Shida Kartli (50%).

It was very interesting to learn that the frequency in the use of illuminated signs in Kvemo Kartli (20%) and Shida Kartli(20%) were higher, even higher than reported for Tbilisi (10.8%).

Diagram 2 Distribution of RH/SH services by presence of inscription/signs at the entrance (%) ?
Does the reproductive cabinet or family healthcare center office have any inscription/sign at the entrance?

Yes, an illuminated sign 8% No, no sign at all 10% Yes, not illuminated sign 82% 22 The analysis based upon the types of medical facilities demonstrated that signs on the facades of women’s consultation centers were always posted (100%), among them the illuminated sign was in one out of ten instances.
Mostly the signs of RH/SH services were not posted on the ambulatories (25%), an lightened signs more frequently were found on the fronts of Family medicine centers (25%).

This may be explained due to better financing of newly created centers and support from various programs.

21 7 Absence of signs inside RH/SH services facilities are more frequent (36.6%), than compared to presence on building fronts (10.5%).
Also, their absence inside the building for the services intended for women are more frequent (41.8%), than in the services created for men (16.1%).

In villages these kind of signs were only found in one of every ten cases (10%), in towns the level is approximately two out of three cases, (67.1%).

The regional display of signs was demonstrated to be the highest in Imereti (95%) and the Kvemo Kartli regions (80%).
However, there was not a significant difference between other regions (ranging from 46.7 – 66%), and from just under half of instances and the frequency increased to a maximum of two out of three.

Besides, no significant difference was detected among the types of medical facilities visited.

Displaying of signs were relatively comparable high at hospitals (76%) and private clinics (72.2%).
Medical staff IDs were displayed more frequently than other types of identification, a little more than 1 out of every two staff members (58.2%), which was even twice higher in towns with six out of 10 visited facilities (60%), compared to villages (30%).

According to the regions the display was highest in Shida Kartli (80%) and the lowest in Imereti (30%).

The highest display based upon the type of facilities was among private gynecological clinics (72.7%).
The indicators for the remaining facilities fall within 48.6-68%.

Accessibility to RH/SH services for youth is determined for the most part with ease of scheduling.

The survey demonstrated that a range of scheduling opportunities is not readily available as the average indicator was 30%.

Scheduling opportunities were more frequently available for young men (55%), than compared to young women (45%).
There was no difference between the rural and urban health facilities, but when a comparison was made at the regional levels, significant differences were identified.

Opportunities for visit flexibility to appoint slots for suitable time frames were more frequent in Kvemo Kartli (80%), and based on the same scoring index, dropped to 0 in Imereti and the Samegrelo region.
The opportunity for visits at suitable time for youth was honored more frequently in family medicine centers (50%), in ambulatories (50%) and hospitals (44%).

Taking into consideration lifestyles of Georgian youth (education, lack of time, more and more actively working) and specific social-psychological features (impatience, difficulty in making decisions, etc.
), there is a real need to allow for more flexibility in being able to have better accessibility to medical facilities, as they need to be able to easily obtain medical treatment.

Based on such initial finding, several practical factors in RH/SH services were further investigated, which included the opportunity to make appointments in advance.

This has the advantage of reducing for patients waiting time for services.
However, scheduling of appointments is actually practiced only in the 40% of the surveyed facilities, and this practices is mainly found among facilities that offer services to young males (54.8%).

Scheduling the visits for women’s consultation centers was not a frequently used practice (36.1%).

In this regard no differences were noted between towns and villages.
However, the differences between regions were rather drastic, and such a vast difference was especially the case for Adjara (0%) and Samegrelo (13.3%) regions, with the lowest recorded scores.

Any difference between various types of facilities was perceived to be only slight.

The lowest indicator had maternity hospitals (22.2%) and private gynecological clinics with an average rating of (36.4%).

22 8 Diagram3 RH/SH services and opportunities for young patients to convenient scheduling ?
Does the health care facility give the opportunity for young patients to arrange visits within a suitable time slot?

No 30% YYes 70% Male 55% 45% 24% 76% Female Yes No 33 The main challenge for youth in accessing reproductive health services is the long waiting time.

The survey revealed that in the majority of facilities the time that patients had to wait to see medical personnel was not longer than from 0-5 minutes (75.2%).
Only slight differences were noted for females and males (73% vs. 83.9%), and there were no instances of males having to wait for more than10 minutes at male consultation centers.

Females had to spend more than 10 minutes in 13.9% of cases.

In the absolute majority of rural medical facilities, (100%) young patients never had to wait longer than 5 minutes.
Among the different towns surveyed, the length of waiting time was between 5-10 minutes in 30.4% of instances for young patients in accessing RH/SH services.

Based on a regional comparison, the lengths most frequently noted among the longest waits (5-10 minutes – 35%; 10 minutes and more – 25%), as experienced by patients in the Imereti region.
After the analysis according to the types of facilities, it was identified that duration of waiting time of patients in out-patient clinics proved to be the shortest in all instances (100%).

It is clear that need for visiting the doctor several times to obtain the full course of treatment prolong the treatment time.

However, such instances are rare (4.6%).


Such an extended treatment period was found only in the case of women (5.7%) and no case was ever reported among male services in villages and among the regions, other than some instances in Tbilisi.

When comparing the different types of medical facilities, however, the above-mentioned situation was the most frequently noted in private clinics (11.1%), including private gynecological clinics (9.1%).
Regardless, it was never recorded for family medicine centers, out-patient clinics, hospitals and polyclinics.

Nonetheless, providing full service may require the patient to make several visits to complete a course of treatment.

However, in better-organized medical services, such conditions can be easily reduced to a minimum.

23 9 Diagram 4 Distribution of RH/SH services based on possibility of pre-scheduling visits ?
Is it possible to schedule the time of the visit beforehand to avoid long waiting periods?

No 60% Yes 40% Tbilisi 50% 50% Imereti 30% 70% Adjara 100% Samegrelo 13% 87% Kvemo Kartli 70% 30% Kakheti 44% 56% Mtskheta_Mtianeti Shida Kartli 67% 60% Yes 33% 40% No The ability of medical personnel to communicate with the patients in their native language helps to increase the accessibility of medical service.
This was well-demonstrated by quite high indicator (97.4%), and only slight differences between women and men, towns and villages, also between regions and types of medical facilities 90.5% vs. 100%) were noted.

44 1.2 Financial accessibility (affordability) to RH/SH services In terms of providing the care about youth health, it is very important factor for RH/SH services to be affordable to clients.

The lack of financial resources for youth using RH/SH services are based on several specific factors.
The youth target group is at a period in their lives (studying period, unemployment) with almost no income or very scarce resources.

Family income is very limited for the vast majority.
Besides, in many instances teens are unable to address family for assistance in solving their intimate problems5,6, so the availability of special financial benefits (discounts) and governmental and non-governmental free-of-charge programs will increase the financial accessibility of youth in the ability to secure necessary and high quality medical treatment, not only to protect, but also to improve their reproductive and sexual health status.

5 UNFPA Framework For Action on Adolescents &Youth 2007.
6 Research Issues in Sexual and Reproduqtive Health for Low and Middle-Income Countries _- Global forum for Health Research and World Health organization 2007.

24 10 Diagram 5 RH/SH services offering special discounts and fee schemes for young patients ?

Where there any special discounts in the given unit and different fees for young patients?
Yes 4% Difficult to answer 1% No 95% 55 The survey identified that health facilities working within the RH/SH sphere only on rare occasion offer special discounts or a varying scale of tariffs for younger patients (3.9%) and even these schemes are available to young women only (4.9%), and only in case they live in towns (4.2%).

Analysis of regional situations displayed some very interesting results.

In Kakheti region was found the highest frequency of offering special tariffs to young patients (22.2%).
In Samegrelo this indicator was just 6.7%, and in Tbilisi 4.1%.

None of the other regions provided any special fees in this regard.

Also, financial benefits or other discounts were not found to available in any of the surveyed maternity hospital or department, family medicine centers and hospitals.

A relatively high indicators were registered in out-patient clinics (12.5%) and private gynecological clinics (9.1%).
Definitely much efforts are needed for the government to provide funding for such programs that provide free-of-charge medical service for youth.

Also, it is essential to inform patients about the financial benefits of such services.

According to the survey, it was determined that obtaining of this information from medical personnel was only in 7% of cases and it was provided only for young women (9%).

Moreover, there were no significant differences between the rates in towns and villages.
According to the survey it was determined that patients were not provided with this information at all in Kakheti, Mtskheta-Mtianeti and Shida Kartli regions; the highest indicator of providing patients with this information was found in Adjara (12%) and Kvemo Kartli (10%).

Among various types of medical facilities, the highest frequency of providing young patients with the information about governmental programs of free medical service was observed in maternity hospitals or other departments (14.8%).
A lower frequency was observed in women’s consultation centers (9.5%) and in private reproductive health clinics (9.1%).

Family medicine centers and ambulatories did not provide such information.

25 11 Diagram 6 Information about free governmental programs When you questioned the health provider did they provide you with information on ?

state programs, which you have right to use free of charge?
Yes 7% 110 100 90 80 70 60 50 40 30 20 10 0 No 93% 93 95 88 87 90 100 100 100 7 5 12 13 10 i s i l i b T % i t e r e m I Yes a r a d A j No l o e r g e m a S i l t r a K o m e v K i t e h k a K - a t e h k s t M i t e n a i t M i l t r a K a d h S i 66 There may be several reasons for the low frequency of informing patients about free medical services in RH/SH sphere.

Namely, it can be attributed to dearth of such programs and absence of such programs for male patients.
The different frequencies among medical personnel in informing patients about services may vary according to specific regions and the types of medical facilities, which may individually have characteristics that differ from the standard.

Differences between regions may also be conditioned by the limited or absence of governmental and regional programs in the first place.
Moreover, it can be assumed that out-patient clinics and Family Medicine centers are visited by young patients with diagnoses that are not included in governmental free medical programs as a matter of policy.

26 12 2.

Informative-educational opportunities for youth in RH/SH services Main sources of informing and educating youth in RH/SH issues are health facilities (educational conversations conducted by medical personnel, availability of informational-educational materials in medical facilities).
(1;1) It is well known in terms of social marketing that the presence of informational-educational materials in the waiting room of the facility serves several purposes.

On the one hand it serves the aim of informing and educating youth about the RH/SH sphere, and on the other hand, reading the materials makes it easier for them to wait for their appointment.
Presence of comfortable and relaxing environment is one of the most important factors in becoming acquainted with such educational materials while in the waiting room.

Survey demonstrated that comfortable waiting rooms were not a frequent event in medical facilities (65%), and slight differences were noted between females and males services (63.9% and 67.7%).

There was a significant difference between towns and villages.
Access to a comfortable environment in a waiting room was found twice often in towns (67.1%), when compared with villages (30%).

Regional differences also were significant (22.2% – 80%).

The highest indicators were detected in Kvemo Kartli (80%) and Samegrelo (80%) regions, the lowest – in Mtskheta- Mtianeti (33.3%), and Kakheti (22.2%).

The same differences were demonstrated among the different types of medical facilities.
A comfortable environment was found most often in private clinics (83.3%), which includes private gynecological clinics (81.8%), and less frequently in ambulatories (37.5%).

In the majority of medical facilities (73.9%) lighting was suitable for patients for reading informational-educational materials.

Such an opportunity was more frequent in towns (76.9%) than in villages (30%).

Regional differences were in the range between 33.3% and 86.7%.
The highest indicator was recorded in the Samegrelo region (86.7%), and the lowest in Kakheti (33.3%) and Shida Kartli (20%).

Significant differences were found between different types of facilities, ranging within 37.5%-90.9%.

The highest levels, as it was expected, were in private gynecological clinics (90.9%), and in private clinics (88.9%).

The lowest ratings were demonstrated in ambulatories (37.5%).

A comparable low index was with women’s consultation centers (66.7%) and polyclinics.
The collected data indicated that in private medical facilities the management is more focused on creating a comfortable environment for its patients.

27 13 3.

The quality of care in RH/SH services 3.1 Compliance of medical facilities and medical personnel with the standards The assessment of the conditions in medical facilities was based on three categories of classification (good, medium, poor).

The most frequent assessment was “medium” (48%), followed by - “good” (37%), and then “poor” (14%).
Female RRH/SH services were more frequent assessed as being “good” (41%) as compared to services for male patients (22.6%).

Interesting data was obtained after assessment of the general condition of rural and urban health facilities.

The most frequent score in both in towns and villages was the assessment “medium” (49% and 40%), assessment “good” was almost four times higher in towns (39.2%) when compared to villages (10%).
When compared to towns (11.9%) the assessment category of “bad” was five times more in villages (50%).

A significant difference was not displayed between the indicators in Tbilisi and other towns.

More differences were observed between the regions.

In the Imereti, Samegrelo and Kvemo Kartli regions, almost half of the medical facilities surveyed were rated as “good” and the other half as “medium”.
In the Kakheti and Shida Kartli regions the majority of medical facilities were considered as facing “bad” conditions (55.6% and 80%).

Significant differences were found when rating according the types of medical facilities; the category “good” was most frequent assigned for private gynecological clinics (54.5%), and slightly less for women’s consultation centers (52.4%), and for out-patient clinics (37.5%).

Family medicine centers were more positively evaluated (62.5%).
In most cases condition of polyclinics and hospitals were assessed as “medium”.

Diagram 7 RH/SH services in terms of comfortable environment in waiting room ?

No 35% Was the waiting room and environment itself comfortable for patients?
Yes 65% Tbilisi Imereti Adjara Samegrelo Kvemo Kartli Kakheti Mtskheta-Mtianeti Shida Kartli 73% 65% 41% 80% 80% 22% 33% 40% 27% 35% 59% 20% 20% 78% 67% 60% Yes No 7 7 For the assessment of the question “how clean was the facility in general”, respondents had to use 5 categories of assessment: very clean, clean, average clean, unclean, very unclean.
It appeared that this assessment for the majority of facilities in total was “clean” 37.3% and “very clean” (30.7%): 28 14 the assessment “unclean” was meant for less then 1/3 of facilities (30.7%).

It was determined that the cleanness was well provided in the facilities that were allocated in towns and served females.

Diagram 8 Distribution of RH/SH services according general condition of buildings ?

How would you assess the condition of the medical facility in general?
Bad 14% Fair 48% Good 37% 8 8 According to the majority of respondents (94.8%), the doctors’ offices were found to be clean.

This indicator was lower in villages, compared to towns (60% and 97.2%).

Somewhat the same was the indicator according to the types of medical facilities and regions, with the lowest in Shida Kartli region (60%).

According to the majority of assessments (96.1%) the cleanness of medical personnel uniform was as it supposed to be.
Though assessment of this parameter was comparably lower in rural medical facilities (70%), comparing with the same type of facilities allocated in towns (97.7%).

Significant differences between the types of medical facilities and regions was not observed.

The assessment was comparably lower in Kakheti (66.7%) and Mtskheta-Mtianeti (66.7%).
The comfortable environment in medical facilities was assessed on the basis of presence of several components: restroom (WC), enough seats, suitable temperature, small table and informational leaflets, TV, music, reading materials, beverages.

The assessment was held by three categories: 4-6 items, 2-3 items and less then 2 items (chart 1.18).

In total the assessment of facilities with 4-6 items were less frequent (17.6%).

The most frequent was assessment by 2-3 items (58.8%).
Also the assessment by less then 2 items was rare (23.5%).

It was found that comfortable environment was more frequent in female RH/SH services, compared to the males RH/SH services.

Though the middle category (2-3 items) prevailed in both cases and was almost equal (59.8 and 54.8%).

After the comparison of RH/SH services of towns and villages it was found, that in towns prevailed the assessment by 2-3 items (60.8%), in villages prevailed the assessment by less than 2 items (60.0%).
Above mentioned results show that there is a lot that must be done in medical facilities for creating the comfortable environment for patients in villages.

29 15 Diagram 9 RH/SH services by general level of cleanness of the facility ?

Average clean 1% Clean 36% How clean was the facility in general?

Unclean 31% Very unclean 1% Very clean 31% 10% 20% 70% 32% 38% 1% 28% 1% Rural Urban Very clean Clean Average clean Unclean Very unclean There were detected sharp regional differences.
The differences were also observed according to the different types of medical facilities.

Among regions most frequent assessment by 4-6 items was found in Kvemo Kartli (30%) and Tbilisi region (25.7%).

In Samegrelo (80%), Adjara (76.5%), Imereti (70%) and Tbilisi (60.8%) prevailed the assessment by 2-3 items.

In Kakheti (88.9%), Shida Kartli (100%) and Mtskheta-Mtianeti (66.7%) most frequent was assessment 2 and less items.
It is interesting, that the assessment in Kvemo Kartli according to all the three categories were almost equal (30%, 40% and 30%).

The most prevailed assessment in more than half different types of medical facilities was assessment with 2-3 items (50%-81.8%).

The most frequent assessment by less then 2 items was for Ambulatories (37.5%), hospitals (32%) and polyclinics (31.4%).

It was somewhat unexpected that the frequency of the same results was found to be comparatively high in private clinics (27.8%).
In private gynecological clinics assessment by less then 2 items was not found at all.

Women’s consultation centers had most frequent the assessment by 4-6 and assessment by 2-3 items (28.6% and 61.9%), in family medicine centers (25% and 62.5%) and private gynecological clinics (18.2% and 81.8%).

In total prevailed the people satisfied with the work of RH/SH services (41.8%).

Also the assessment “quite satisfied” prevailed over other assessments (30.7%).
The frequency of the assessments “dissatisfied” and “very dissatisfied” was low (5.9% and 1.3%).

1/5 of the patients were “Neither satisfied nor dissatisfied” (20.3%), thus the frequency of “satisfied” with medical service appeared to be quite high – more than 70%.

The frequency of “satisfied” in urban medical facilities were twice higher compared to rural facilities.

In towns “quite satisfied” were 32.9%, at the time in villages this category wasn’t found at all.
In rural medical facilities prevailed the category “neither satisfied nor dissatisfied” (70%).

There were significant regional differences.

In Imereti the most frequent was category “quite satisfied” (55%) and “satisfied” was frequent compared to other categories (25%).
The results in Kakheti region showed that the most frequent was category “neither satisfied nor dissatisfied” (44.4%), the frequency of “satisfied” and “dissatisfied” were 30 16 equal (22.2% - 22.2%) and compared to others the frequency of “very dissatisfied” was quite high (11.1%).

According to the different types of medical facilities the best results were found for private gynecological clinics.

Diagram 10 RH/SH services by appropriate dressing of medical personnel ?
Were the medical personnel dressed neatly, as medical professionals should be?

No 4% Rural Yes 96% Urban 70% 30% 98% 3% Yes No 1010 In terms of improvement of medical service, as in case of any service, receiver’s opinion is important, in this case - the attitude of patient.

How he/she assesses the service, how this service should be improved.

The management should be organized with the foresight of these results, to make this service more acceptable for patients.
According to the survey, it was determined that the question “what needs to be changed to make this service more acceptable”, is asked very rare (2.6%) and basically in male service centers (12.9%).

This question is more frequently asked in villages (10%), than in towns (2.1%).

It is somehow difficult to explain the regional differences.

This question is quite frequently asked in Mtskheta-Mtianeti region (33.3%), very rare in Tbilisi region (1.4%) and never has been asked in other regions.
From different types of medical facilities this question was rarely asked only in private clinics (5.6%), hospitals (8%) and polyclinics (2.9%).

In general it is pity, that the study of patients’ opinions on improving the management is not used in Georgia.

31 17 Diagram 11 Satisfaction with doctor’s visit ?

50 40 30 20 10 0 % Generally how satisfied were you with a visit to a doctor?

42% 31% 20% 6% 1% Quite satisfied Satisfied Neither satisfied, nor dissatisfied Dissatisfied Very dissatisfied 3.2.
Confidentiality and privacy in RH/SH services One of the necessary conditions for maintaining the confidentiality is the availability of comfortable environment in doctor’s room for the consultation and talking around the intimate topics for the patient, that according to the survey was observed in majority of cases (74.5%).

Comfortable environment was more frequently mentioned in male’s services (87.1%), as compared to women’s services (71.3%).
Higher differences were displayed between urban and rural medical facilities (77.6% and 30%).

The comfortable environment was more frequently presented in Tbilisi (82.4%), than in other towns (72.5%).

Significant differences were detected according to the regions; the highest indicator was displayed in Imereti (90%), the lowest in Mtskheta-Mtianeti (33.3%).
The differences were not so sharp according to the types of medical facilities, but as it was expected, the high frequency of availability of comfortable environment was in private clinics (83.3%) and in private gynecological clinics (81.8%).
The special isolated place in doctor’s room for patient consultation was present in majority of studied medical facilities (71.9%), more frequently in towns (73,4%), than in villages (50%) and in services meant for males (80.6%), compared to the services for females (69.7%).

But as it is seen, the difference is not that sharp.

The differences among regions were mainly found between Imereti (95%) and Kakheti (44.4%) regions.
Slight differences according to various types of medical facilities are difficult to explain based on any standard.

32 18 Diagram 12 Satisfaction level as asked about ways to improve provided services ?

Were you asked whether or not you were satisfied with the service and what else could have been done to improve it?

Yes 3% No 97% 1212 The level of the assessment of confidentiality in general was positive in majority of cases (68%).
The assessments according to each component are almost coinciding with the assessments obtained from previous questions.

The confidential environment with the lowest frequency was displayed in Kvemo Kartli (40%), Kakheti (44.4%), Mtskheta-Mtianeti (33.3%) and Shida Kartli (20%).
Presumably differences in presence of confidential environment according to the location and types of medical facilities is determined not only with the existing objective factors, but also with the lack of understanding and requirement of importance of creating such atmosphere both from doctors and patients.

For the assessment of the confidential environment in doctor’s room, was also used question regarding the presence of third person in the room.
It was found: third person was presented in the room in almost ¼ of cases (22.2%), more frequently during the women’s visits (26.2%) compared to the men’s visits (6.5%) and in villages - (40%) compared to towns (21%).

There were detected significant regional differences.

The highest indicator was in Mtskheta-Mtianeti (66.7%), the lowest in Imereti (0%), that somehow coincide with the regional peculiarities that was identified from questions.
According to the types of medical facilities there were no sharp differences.

The request of patient for creating the confidential atmosphere in case of absence of it, were taken in consideration in 1/3 of cases and only in towns (38.1%).

There were identified sharp differences between regions (0% - 100%) and according to various types of medical facilities (0% - 60%), though there were no definite standards.
33 19 Diagram 13 RH/SH services as to availability of comfortable environment for consultations and intimate discussions ?

In your opinion, was the environment suitable to conduct a confidential conversation and receive consultations during your visit?

30% 70% 78% 22% Yes 74% Rural Urban Yes No 1313 No 26% In majority of cases (60.1%), in medical facilities it was impossible to hear confidential information of other patients during medical service or being in waiting room.
In 31.4% of cases it happened because other patients were not present and only in 8.5% of cases the confidentiality wasn’t maintained.

In this case also men were in better condition than women.

There were also no significant differences between towns and villages, between regions and between the various types of medical facilities.
In terms of maintaining confidentiality, besides environment, very important is to convince the patient that his/her information will be treated by medical personnel as confidential.

The patient may be convinced by doctor, or patient must get an impression of this.

A part of patients (44.4%) have received a guarantee of this at the beginning of their visit, others received after the asking of this question (38.6%) and only a slight part couldn’t receive it (17%).
Confidentiality was less guaranteed for males (35.5%) compared to females (12.3%).

The guarantee of keeping the confidentiality more frequently wasn’t received in villages (40%), then in towns (15.4%).

Significant differences according to the various types of medical facilities were not found.

The regional differences were quite obvious and somewhat coincide with the results of existence of confidential environment in studied facilities.
The guarantee of keeping confidential information by doctor wasn’t received frequently in Mtskheta-Mtianeti (66.7%), less frequent in Imereti (5%).

After the visit the majority of “patients” (enumerators) (79.9%) had impression, that the information provided to doctors will remain confidential, almost equally to men (83.9%) and women (78.7%).

This impression was less in villages (50 %), compared to towns (81.8%).

The regional differences were not significant.


The exception was Kvemo Kartli, where this indicator was minimal (40%).

According to the various types of medical facilities the highest score had private gynecological clinics (100%) and lowest – women’s consultation centers (66.7%) that was somehow possible.

34 20 Diagram 14 RH/SH services with guaranteed confidentiality ?

Were you guaranteed that your visit would be kept confidential?
No 17% Yes, after my question 39% 19% 45% 35% 51% 37% 12% Male Yes, at the beginnig of conversation 44% Female 10% 50% 40% 47% 38% 15% Rural Urban Yes, at the beginning of conversation Yes, after my question No In terms of keeping the privacy in RH/SH services it is necessary to provide possibility for making tests and visiting doctor anonymously.

According to the survey in total confidentiality of visits were kept in more than half cases (57.5%).
Besides, the anonymity in male’s services and in villages were kept more often that in women’s services and in towns.

Also, the difference between Tbilisi and other towns were quite significant (68.9% and 43.5%).

Significant difference was found among the regions varying from 15% to 88.2%.

It is difficult to explain the lowest indicator in Imereti region (15%).

The low indicators were received in Samegrelo (33.3%) and Shida Kartli (40%).

Highest indicator was obtained in Adjara (88.2%).


The differences between various types of medical facilities were not sharp (48% - 81.8%).

As it was expected the highest rate was identified in private gynecological clinics (81.8%) and in private clinics (72.2%), and lowest in hospitals (48%) and in polyclinics (48.6%).
It must be mentioned that some patients don’t feel the confidential service is necessary, though the personnel must give to the patient information about the possibility of confidential service in advance, that patient may not know.

It must be mentioned, that the one of the best conditions for maintaining confidentiality – availability of separate entrance for youth – was available in none of the surveyed medical facilities.
3.3 Attitudes of RH/SH service medical personnel towards youth Attitudes of RH/SH service medical personnel towards youth was assessed by means of certain parameters.

It was determined that in majority of cases in facilities medical personnel greeted patients on each visit.

Almost no differences were found between female’s and male’s, between urban and rural facilities.
Slight differences were detected according to various types of facilities (87.5%-100%) and according to regions (80%-100%); exception was Kakheti where the lowest rate was observed (66.7%).

The highest indicator was in Imereti (100%).

35 21 Diagram 15 RH/SH services as to how patients’ were greeted appropriately or not ?

Did the medical personnel greet you?


Yes 92% No 8% In the registrar’s office doctor was chosen by the patients in more than half cases (61.4%), more frequent for males (71%), than for females (59%), also more frequent in towns (62.2%), than in villages (50%).

Patients requests were met in family medicine centers (75%), hospitals (72%) and private gynecological clinics (72.7%), compared to the private clinics (50%), ambulatories (50%) and polyclinics (54.3%).
Choosing the doctor by young patients greatly varied in regions.

Unexpectedly, the lowest indicator was in Imereti (20%) and Samegrelo (46.7%) and highest - in Mtskheta-Mtianeti (100%).

Benevolent attitude towards youth from medical personnel could also be determined with polite explanation of reasons of impossibility to choose a doctor, which generally wasn’t happening so frequently (28.8%).
The indicator was again higher for males (44.4%), than for females (26%) and higher in villages, compared to towns (accordingly 40% and 27.8%) It is very interesting that the indicator was lowest in Imereti (6.3%), and in Adjara (100%), Kvemo Kartli (100%) and highest in Shida Kartli (100%).

Medical personnel’s attitude towards patients during visit was also assessed.

It turned out that in majority of medical facilities medical personnel was polite (97.4%).
Differences according to the facilities, regardless their location and designation, were minimal and indicators – were highest in majority of cases (100%).

It turned out that besides the politeness, medical personnel’s attitude towards youth was friendly in majority of cases (89.5%).

The differences between the facilities according these parameters were not exceeding 20 %.

Youth deserve respect and assistance regardless the age and often unstable social-economic condition6,7.
Readiness of medical personnel to assist and respect youth was assessed according to three degrees (2-4, 1-2 and <1).

It was found that medical personnel showed readiness for 6 Research Issues in Sexual and Reproduqtive Health for Low and Middle-Income Countries _- Global forum for Health Research and World Health organization 2007.

7 Adolescent Friendly Health Services – An Agenda for Change – WHO/CAH/02.14 – World Health Organization, October 2002.
36 22 assistance and respect towards young patients frequently with high degree (2-4) (55.6%), with average degree (1-2) – in 41.8% of cases and very rare – with low degree (<1) (2.6%).

The readiness for assistance and respect towards males was shown with higher degree (2-4 – 77.4%, 1-2 22.6%, <1 -0%), compared to attitudes towards females (2-4 – 50%, 1-2 46.7%, <1 – 3.3%); Diagram 16 Degree of respect demonstrated by medical personnel ?
60 50 40 30 20 10 0 % Did the medical personnel show respect and support to young patients?

55% 42% Great deal Somewhat respect None at all 3% After the comparison of data obtained from towns and villages, it was identified that showing of readiness for assistance and respect towards young patients from medical personnel was higher in towns, though the difference was not sharp.

The differences were more significant according to regions, but that was mainly related to the assessments of 2-4 and 1-2 points.
Assessment with the point <1 was found in Imereti (5%) and Kvemo Kartli (10%).

It is interesting that this assessment in Mtskheta-mtianeti was highest (2-4).

In Imereti also the assessment with the points of 2-4 was high (7-%), where the assessment of <1 point also was found (5%), that we didn’t face in majority of regions.

Some obtained results were quite illogical for certain types of medical facilities.
For example, in private clinics the assessment with 2-4 points was one of the highest (77.8%), also in 5.6% of cases there was assessment with <1 point, that in total is rare.

In the polyclinics the assessment with 2-4 and 1-2 points were with almost the same frequency (48.6% and 45.7%) and also there was assessment with <1 point (5.7%), that indicates, that medical personnel in polyclinics show less respect and readiness for help towards youth.
In women’s consultation centers above mentioned attitude was mainly shown with average degree (1-2 points) (61.9%), though the assessment of less than a point was not displayed at all.

Probably the explanation of obtained illogical results is the individual differences of medical personnel and “patients”.

Lack of availability of RH/SH services for youth makes the barrier, such as condemnatory attitude because of their shocking problems (extramarital pregnancy, contraception, abortion, etc.
)6,8,9 So 6 Research Issues in Sexual and Reproduqtive Health for Low and Middle-Income Countries _- Global forum for Health Research and World Health organization 2007.

37 23 one of the goals of the survey was to determine whether the condemnatory attitude towards the youth, who visited RH/SH services because of such problems, from medical personnel was noticeable or not that evolved due to non acceptance of their behavior for society.
It turned out that in majority of cases of abovementioned situations condemnatory attitude from medical personnel was not noticeable (82.4%), mostly towards females (85.2%), comparing to males (71%).

The differences according to regions were not sharp in spite the fact that a condemnatory attitude in Mtskheta-mtianeti and Shida Kartli was not detected at all.

Most frequent the condemnatory attitude was in Adjara (29.4%).
Also, most frequent condemnatory attitude was noticeable in maternity hospitals (22.2%) and in women’s consultation centers (33.3%), most rare from the medical personnel of hospitals (8%) and private gynecological clinics (9.1%).
Very often repeated visit to medical facility is conditioned with the manner the doctor farewells him/her after the visit, that is determined not only with the form (politely, warmly, or indifferently), but also according to the context (whether he/she has explained the importance of further examinations, the necessity of visit, expressed support, promise to help and etc.).
It was determined that in questioned facilities in majority of cases the doctor offers help to patient (66%), almost with the same frequency to males and females.

This attitude from doctors in towns are determined with twice or more frequency (68.5%), comparing to villages (30%).

The differences were sharp according to regions.

In Mstkheta-Mtianeti the corresponding indicator was 100%, in Kakheti – 22.2%, the same indicator was comparably high in Adjara (76.5%).
According to various types of medical facilities the figures varied between 60%-75%.

The exceptions were the private gynecological clinics, where all doctors while farewelling were offering the assistance (100%).

Diagram 17 RH/SH services as whether the doctor represented any judgmental attitude ?

No 82% Was there any kind of condemnatory attitude on the part of a doctor?
29% 71% 15% 85% Yes 18% Male Female Yes No 1717 8 The world reaffirms Cairo: official outcomes of the ICPD at ten review (New York: UNFPA, 2005.

9 World Leaders Statement in Support of ICPD, 2004 38 24 3.4.

The quality of medical service and consultations in RH/SH services.

In obtaining high quality medical service in RH/SH sphere comprehensive consultation has the great importance that is especially important for young patients.
Though several parameters have been used for assessing the quality of the consultations in RH/SH services.

It was determined that on consultation doctor was listening fully and attentively to the majority of patients (94.1%).

Only a few doctors were losing focus (5.2%) during the consultation and a very slight part couldn’t listen to a patient because of too much work.

The difference between town and village was slight, but in the village the doctor was always listening patient attentively (100%).
The differences according to regions and types of medical facilities in majority of cases were not significant.

(90%-100%) and doctors were attentively listening to patients.

The exception among regions was Kakheti and Shida Kartli, where the attention towards patients from doctors was less (66.7% and 80%).

In Kakheti was the highest frequency of doctors having a lot of work (11.1%) and were losing focuses (22%).
This tendency most frequently was found in polyclinics, where doctors were losing focuses while listening to patients (14.3%).

In majority (90.2%) of cases doctors were questioning patients for precise identification of problems.

The differences were sharper according to regions.

The highest rate was displayed in Samegrelo (100%), lowest in Kakheti (66.7%) and Mtskheta-mtianeti (66.7%).
Among different types of medical facilities doctors for precise identification of problems were questioning patients in all cases in women’s consultation centers and private gynecological clinics.

This indicator was lowest in Polyclinics (82.9%).

Diagram 18 RH/SH services as whether the doctor carefully and fully listened to patient during whole visit ?

No, he was ofter got distracted 5% No, he was too busy 1% Did the doctor listen to you carefully and till the end?


Tbilisi Imereti Adjara Samegrelo Kvemo Kartli Kakheti Yes 94% Mtskheta-Mtianeti Shida Kartli 3% 10% 97% 90% 100% 100% 90% 67% 10% 11% 22% 100% 80% 20% Yes No, he was too busy No, he was ofter got distracted In majority of cases there was impression, that doctors have exactly learned about patients problem (83%).
In part of cases (16.3%) the doctor couldn’t fully understand the problem of patient and only 39 25 a slight part considered that doctor couldn’t understand about patient’s problem.

(0.7%) In total detected situation is close to the situation that exists in towns.

In villages in majority of cases patients considered, that doctor couldn’t understand their problems (60%).

Sharp regional differences were displayed.


In Mtskheta-mtianeti in 100% of cases there was impression that doctor could understand patient exactly, meanwhile this showing was minimal in Kakheti (33%).

In none of the regions was impression that doctor couldn’t understand patient’s needs, it was only found in 5% of cases in Imereti.
It was somehow unexpected, that discerned from other medical facilities, only in private clinics was created the impression that doctor couldn’t understand patient’s needs (5.6%).

Understanding problem exactly was highest in private gynecological clinics (100%), lowest - in ambulatories (50%).

Indicator obtained from other medical facilities was comparably low in women’s consultation centers (66.7%) and polyclinics (77.1%).
In difference from adult patients young patients, due to their inexperience and psychological particularities may more frequenty be tended to consider that doctor have exaggerated their condition.

According to the survey it was determined that in total this situation wasn’t that much frequent (4.65%).

This kind of impression was more frequent (9.7%) in young males than young females (3.3%) and more frequent in villages (10%) than in towns (4.2%).
According to the regions this indicator was highest in Mtskheta-mtianeti (33.3%), less frequent – in Shida Kartli (20%) and in Adjara (11.8%).

In the rest of the regions this kind of impression wasn’t created.

Among different types of medical facilities in maternity hospitals, family medicine centers, ambulatories and private gynecological clinics there wasn’t impression of worsening and exaggerating patient’s condition.

The indicator among other facilities varied between 9.5%-5.6%.
Diagram 19 RH/SH services based on how precisely doctor identified the patient’s problem ?

Do you think that the doctor identified precisely what your problem was?

Did not understood 1% I'm not sure that he found it out fully 16% Yes, precisely 83% Distinguishing the problem and gaining trust, especially among young patients, requires from doctors high professionalism, patience and alocation of appropriate time.
Determining one of the above mentioned components for high quality consultation was done with survey.

The time spent to 19 19 40 26 patient during the visit to doctor was estimated with three categories.

It was found that in majority of cases (86.3%) doctor was spending as much time as patient needed.

According to this category almost the same results were obtained for females and males (87.1% and 86.1% accordingly).

There significant difference was found between towns and villages.
In towns most frequent was the category “adequate amount of time was spent with me” (88.8%).

In 9.1% of cases the doctor was hurrying to shorten the visit, and very rare (2.1%) doctor tried to get rid of patient.

In villages first two categories were met with the same frequency (50%), and the third category wasn’t mentioned at all.
The result was somehow unexpected, because big flow of patients is not expected in villages, so the intention to finish the visit quickly may be explained with subjective factors (indifference towards the patient, lack of knowledge in principles of consultation, etc.).

Diagram 20 Distribution of RH/SH services according to time allocated during doctor’s visit ?

How much time did the doctor spend with you?


Tried to get rid of me 2% Tried to shorten the visit 12% An adequate amount of time was spent with me 86% 20 20 Regional differences were significant.

For the category “adequate amount of time was spent with me” have received the highest indicator in Kvemo Kartli (100%), lowest – in Kakheti (44.4%).

Comparably low was this rate in Shida Kartli (60%).
Accordingly, rates of the categories “Tried to shorten the visit” (44.4%) and “Tried to get rid of me” (11.1%), according to frequency highest was in Kakheti.

Among different types of medical facilities doctors “Tried to get rid of patient” only in maternity houses, women’s consultation centers and that was somehow unexpected in the private clinics (accordingly 3.7%, 4.8% and 5.6%).

The category “An adequate amount of time was spent with me” varied between 75%-100%.
Its highest rate (100%) was found only in private gynecological clinics.

Among RH/SH rights the most important are the right to education and the right to receiving information, mainly concerning the preference of methods for birth regulation and avoiding undesirable pregnancy, its risks and efficacy.
Every human is free in his decision concerning the number of children and interval between deliveries, as well as in choosing and using appropriate method for avoiding unplanned pregnancy.10 10 ICPD Programme of Action, 1994.

41 27 According to the survey it was found that in total complete information about medical treatment and about all alternative contraceptive methods was given by doctor in majority of cases (52.3%), incomplete – in 39.2% and haven’t given at all in 9% of cases.
As well, giving the information in female RH/SH services was more frequent (54.1%), than in male RH/SH services (45.2%).

Not giving any information showed opposite results – in male RH/SH services in happened more frequently (16.1%) than in female RH/SH services (6.6%).

In rural medical facilities the frequency of not providing full information prevailed (50%), and giving the full information was happening less times (30%), compared to towns (53.8%).
Not giving any information also prevailed in villages (20%) comparing to towns (7.7%).

Diagram 21 Information and alternatives for reproductive health ?

Were you given enough information on alternative ways of treatment and contraception methods?

No 9% Yes, full information 52% 45% 39% 16% 54% 39% 7% 30% 50% 20% 54% 38% 8% Male Female Rural Urban Partial information 39% Yes, full information Partial information No Significant regional differences were detected.
The best results were in Adjara, where the frequency of giving complete information was highest (88.2%), quite a few – the frequency of not giving adequate information (11.8%), not giving information at all wasn’t displayed at all.

The worst showing was displayed in Shida Kartli, where shoving of giving full information to patients was the lowest (20%) and highest – of not giving any information at all (40%).

Comparably unsatisfactory was the situation in Mtskheta-mtianeti and Kakheti regions.
Among different types of medical facilities the best results were displayed in family medicine centers (giving the full information 75%, not giving any information at all – 0%) and in private clinics (giving the full information 61.1%, not giving any information at all – 0%).

In previous chapters a diversity of characteristics of RH/SH services (such as compliance with medical standards, physical and financial accessibility, privacy, confidentiality,etc.)
were discussed that gives an opportunity to assess whether certain RH/SH services are benevolent towards youth or not.

It also must be mentioned that one of the main characteristics of youth friendly services is providing high quality medical service.7 This can be assessed during consultation bsed on how 7 Adolescent Friendly Health Services – An Agenda for Change – WHO/CAH/02.14 – World Health Organization, October 2002.
42 28 doctor identifies the problem, prescribes the proper examination (check-up), defines strategy for medical treatment, displays all alternative methods for medical treatment and contraceptives, establishes proper communication, shows support, etc.

For achieving this goal and to learn about the quality of consultations and medical treatment in RH/SH services, the “patients” were vesting abovementioned services according to our 5 different scenarios.

43 29 4.
43 29 4.

Assessment of the quality of medical service and consultation according to scenarios Scenario #1 A 16 years old teenage girl visited medical facility (women’s consultation center, family medicine centre, reproductive health cabinet, etc) and requested consultation with young female doctor.

When meeting the doctor, she asked for a confidential environment.

Reason for the visit: Patient has a doubt that she can be pregnant.
Patient is not married, had unprotected sexual contact with her boyfriend approximately 3 weeks ago.

At present has of 1 week delay in menstrual cycle.

According to the scenario one of the most important issues that doctor had to find out was, what the patient intended to do, if the pregnancy would be confirmed.

According to a survey it was determined that in total this question was asked in majority of cases (77.8%).
Definitely, in case of delay of periods for a week, it must be determined whether she used to have previously delays or not, and whether she has some signs characteristic to pregnancy (vomiting, sleepiness) that she didn’t have before.

80.6% of doctors tried to find out about it.

The fact that gynecological check- up was offered only by 55.6% of doctors, is not a bad figure, because at early stage of pregnancy the gynecological examination is not enough informative.
It was very interesting to find out whether the doctor has offered to patient and how (with imperative or cooperative manner), assistance in involving parents and partner in discussion for problem-solving.

This kind of suggestion happened only in 44% of cases.

Because according to Georgian law11 consultation about pregnancy from 16 to 18 years old doesn’t require parent’s permission, so this question could not be asked.
Thus, offering such assistance shows the youth friendly attitude of the doctor towards a young patient.

One of the most important components in high quality consultation is giving to a patient, especially to a young one, complete information about his/her problem that is necessary for making a sensible decision.

Determination of this component of consultation was made according to several parameters.
Survey showed, that risks of abortions, pregnancy and delivery in teenage was introduced to patients by majority of doctors (77.85) (chart 2.1.3)..

Giving information about safe and unsafe abortion characteristics was happening comparably rare (66.7%).

More rare was given information to teenage patients about the positive sides of sexual restraint and delay of sexual debut (19.4%).
This means that doctors don’t understand or don’t think that it is their responsibility to conduct such type of educational work as giving information about these issues, the role of education in establishing reproductive and sexual behavior.
The most alarming is the fact, that young patient, as it is displayed from the scenario, may in future face the risk of undesirable pregnancy and also risks of STDs, and less than half of doctors (44.4%) explains the ways for safe sex and types of contraceptives, the positive sides and perspective for their use in future.

Also less attention is paid by doctors to explaining to teenage patients about how and when pregnancy can begin (47.2%).
Comparably better was the situation regarding offering the methods for identification of pregnancy (86.1%).

11 reproduqciuli janmrTelobisa da reproduqciuli uflebebis sakiTxebi saqarTvelos kanonmdeblobaSi _ UNFPA Tbilisi, 2004.

44 30 In case of consulting unmarried sexually active teenager, one of the main issues is, despite the reason of visit, to learn about his/her sexual behavior (whether she has regular sexual intercourses, number of partners, etc.)
and accordingly advise the appropriate contraceptive method and offer tests to identify STDs.

With the foresight of the above-mentioned information, only 1/3 (33.3%) of doctors made an effort to learn about such tests and information (Chart 2.1.12).

Determining the risk and offering tests to identify STDs was offered by 38.9% of doctors.
These results show that doctors in RH services don’t pay appropriate attention to determining the risks of SSTDs in gynecological patients and necessity of taking proper examinations.

Scenario #2 A 15 year old teenage girl visited medical facility (women’s consultation center, family medicine centre, reproductive health cabinet, etc) and requested consultation with young female doctor.

When meeting the doctor, she asked for a confidential environment.

She is not married.
She is not married.

Reason for the visit: two days ago patient had unprotected sexual contact and she wants to avoid possible pregnancy, as she had heard about such possibility.

According to scenario, the case is related to a very important for youth issue, urgent (post-coital) contraception.

It is known that sexual contacts among youth are mostly unplanned and unexpected.

So they don’t supply themselves with contraceptive means beforehand; also young people often are the victims of sexual violence.
The above-mentioned situations includes the increased risks of becoming infected with STDs and HIV.

So, importance of urgent post-coital contraception and test on STDs in youth is not doubtful.

Efficacy of urgent contraception is determined with the timing passed after sexual act.

Determination of term is very important and necessary component of the consultation.

According to survey majority of doctors (79.3%) tried to define the term after the sexual act.
During the consultation with doctor, as it is seen from scenario, young people haven’t thought or they just don’t know about the principles of safe sex and it is very important to receive such information.

Unfortunately, only a small number of doctors (17.2%) (chart 2.2.6) have explained to patients when and how pregnancy may begin, what are the positive sides of safe sex and methods of contraceptiion and perspectives of their further use in future (27.6%).
More than half of doctors (58.6%) have explained to patients the positive sides of sexual restraint that also are important for those teenagers who couldn’t delay the sexual debut.

Although gynecological examination in this particular situation is less important for identification of the problem, it was offered with a high frequency (69%).
It also must be mentioned that in such cases gynecological examination may have some kind of importance, as one of the components of preventive examination, as well as diagnosys of STDs.

Informing and educating of patient is very important for making an informed decision, assessing the efficacy of medical treatment and in meeting the expectations.
Giving to the patient information about using various pills for urgent contraception and introducing their efficacy according to the term after sexual act, is very important component of the consultation.

So, the fact that this kind of information was given to patient only by 69% of doctors is not that much good indicator.

Despite the fact that using intrauterine devices (IUD) according to the terms after sexual act is more affective comparing to pills, they are not that popular among youth.
So the doctor must give 45 31 all kind of information about the methods of all kind of emergency contraception and its high efficacy.

Unfortunately this kind of information was given only by 55.2% of doctors.

Also it is doctor who should express support towards young patient and this may be done with explanation where contraceptive pills (in pharmacies) or IUDs (in medical facilities) could be purchased.
This information was given to patient in 65.5% of cases, and assistance about IUDs was offered only by ¼ of doctors (24.1%).

In case of emergency contraceptives, it is very important that the doctor explains different ways of taking different contraceptive pills, because this is the determinant of its efficacy.

Above mentioned rules were explained by 65.5% of doctors (chart 2.2.16).

It is also very important to verify how well the patient has understood given information.
About the side effects of emergency contraceptive pills and IUDs doctor has talked to patient in 58.6% of cases.

In discussed situation it was very important to inform patients that emergency contraception sometime may not be effective, so the repeated visit is necessary to discuss further testing in determining possible pregnancy.

Repeated visit was appointed to 62.1% of patients.


Making an informed decision by the patient in case of pregnancy it is very important to make her acquainted with high risks of abortions, complications of pregnancy and giving birth in teenage.

Unfortunately, only a ¼ of doctors (24.1%) considered that this kind of information must be given to patient (chart 2.2.2).
Characteristics of safe and unsafe abortions was told to patient by less than 1/3 of doctors (31%), though in case of teenagers its necessity is not doubtful.

It is very positive that great majority of doctors (86.2%) have offered their assistance in involvement partner and parents in problem-solving.

Identification of the patients sexual behavior (whether she has regular sexual intercourses, number of partners, etc.)
was done by 37.9% of doctors (chart 2.2.9), as it is very important in selecting the permanent methods of contraception, determining risks of STD-es and AIDs, for determination of the necessity in check ups on these infections and conducting proper informative-educational activities.

As the survey showed, doctors often (72.4%) advice patient to take a test of STDs regardless their sexual intercourses (chart 2.2.8).
46 32 Scenario #3 A 17 years old teenage girl visited medical facility (female consultation center, family medical centre, reproductive healthcare cabinet, etc) and requested consultation with young female doctor.

When meeting the doctor, she asked for a confidential environment.

Reason for the visit: patient wants to terminate 8 week pregnancy.

According to Georgian law11 termination of pregnancy in case of 17 years old patient doesn’t require the obligatory permission of parents.
Though in some cases involvement of partner and parents in problem-solving may have positive results, so offering help in this matter is an expression of support.

This kind of help was offered to patients by almost half of doctors (48.1%).

Unfortunately the frequency of introducing by doctors to patient the risks of complications of abortions, pregnancy and giving birth in teenage was very low (7.4%).
According to above mentioned it was somehow unexpected that explanation about positive sides of sexual restraint and delay of sexual debut was quite high (74.1%).

Less than half of the doctors (40.7%) considered as important to explain to patient about positive sides of safe sex and contraception, and perspectives of their use in future, despite the fact that in specific situation the necessity of this was obvious.

Around half of doctors (51.9%) have explained to patient when and how pregnancy begins.
More than half of doctors (55,6%) tried to determine characteristics of sexual behavior of patient.

One of the main issues during consultation, in above mentioned situation, is determination of how much unavoidable was abortion.

Majority of doctors tried to find out about this (77.8%).. One of the main components of doctor’s strategy, in case of diagnosing pregnancy and its term, making gynecological or other kind of examination was offered by more then ¾ of doctors (77.8%).
In case, when teenager patient should make a choice to make an abortion or to give a birth to a child, she must be acquainted with the results of each choice.

So talking about the responsibilities of being mother is very important, that was done by majority of doctors (66.7%).
Also it is very important that doctor gives the information that if she fears to remain pregnant, because she has heard about the complications of pregnancy and giving birth in teenage, this can be solved with the use of intensive ANTENATAL observation.

This type of conversation was held by the majority of doctors (70.4%) that must be assessed positively, and it is expected that obtained information will be for teenagers a stimulus to be more responsible towards her own and baby’s health during pregnancy.
11 reproduqciuli janmrTelobisa da reproduqciuli uflebebis sakiTxebi saqarTvelos kanonmdeblobaSi _ UNFPA Tbilisi, 2004.

47 33 Scenario #4 A 16-year-old teenage girl visited medical facility (women’s consultation centre, family medicine centre, reproductive health cabinet, etc).

The young lady gave birth to a child two months ago.

She first gave birth to a child at the age of 15.

She did not breast feed the child.


After 3 months she again became pregnant and gave birth to the second baby at the age of 16.

Reason for the visit: The patient wants the doctor to select for her a suitable type of contraception.

At the same time, she worries because her husband would like her to get pregnant again in the nearest future and that is why she requests that her visit remains confidential.
This scenario demonstrates that in the above mentioned situation qualification of doctors should also be considered not only in terms of the best choice of safe and effective contraception methods, but also in addressing problems related to the wrong attitudes of the husband when it comes to the recommendation for the patient to undergo obstetric anamnesis, which is most often determined by the age of the woman.
Based on the obstetric anamnesis, stage of lifespan, and the age of young patient, majority of doctors have offered (73.3%) gynecological examination to their patient prior the choice of contraceptive method.

One of the main concerns, related to husbands wrong attitude when for his 16 years old wife, who already has given birth twice, to become pregnant for a second time and without any break, was not properly assessed by the majority of doctors.
Only ¼ of doctors (26.7%), offered to their patients to bring their husbands to the clinic.

The purpose was to provide the husband with information about the higher risk of and complications of pregnancy and delivery and expediency of keeping two year interval between deliveries.

The majority of doctors (90%) made the correct decision to assist the patient in selection of appropriate contraceptive method in case she was against bringing her husband to the clinic.
In choosing contraceptive methods, it is very important to give patient full information about efficacy, side-effects and expected complications of each method, in order to make right choice.

Majority of doctors (86.7%) informed the patient about the characteristics of above mentioned methods.

In order to make given information fully understandable for the patient few doctors have used illustrated materials (16.7%).
Pecularities of woman’s life periods, acceptability and her character in discussion of various types of contraception was considered by ¾ of doctors (76.7%).. Undoubtfully it should be considered positive that in in majority of cases (83.3%) selection of contraceptive method was done by the patient and doctor jointly (chart 2.4.9).
More than half of doctors (56.7%) have explained to patients where they can purchase contraceptive means, and whether the facility has a supply of free contraceptives that woman can use.

Despite the fact that in given situation there was no direct data about the risks of STDs, that is very important in selecting some types of contraception (for example IUDs), only a small part of doctors (16.7%) have offered patient to take test to identify STD, or tried to determine the risk of their presence.
48 34 Scenario #5 A 18 years old teenage boy visited medical facility (women’s consultation center, family medicine centre, reproductive health cabinet, etc) and requested confidential consultation with young male doctor.

Reason for the visit: Three days ago, while being under influence of alcohol, he had sexual intercourse with a newly acquainted woman.

He is afraid of a high risk of being infected with HIV/AIDS or some other sexually transmitted diseases.
According to scenario after sexual intercourse of teenage boy had passed three days.

For different sexually transmitted diseases latent periods are different, so it is justified if doctor asks about any kind of symptoms, that was done by majority of doctors (96.8%).

It is somehow unexpected that checking and examination was offered to patients only by 64.5% (cchart 2.5.2) of doctors.
Only a very small part of doctors (19.4%) told patient about the possibility of anonymous examination on STDs and HIV/AIDS.

Probably big part of doctors doesn’t understand that possibility of anonymous examinations may be of great importance for teenagers.

Anonymous examination on STDs is fulfilling person’s reproductive rights that relates to confidentiality and privacy.
It can be assessed positively that big majority of doctors (90.3%) have explained the possibilities of presence of STD even in terms of absence of their symptoms.

64.5% of doctors gave informative-educational information about different types of STDs and HIV/AIDS, duration of latent period, their harmful influence on health, etc.

The majority of doctors (67.7%) have explained to patients about the principles and methods of safe sex.
Only little bit more than half of doctors (54.8%) considered it important to explain to patient about the optimal terms of examinations on various STDs and offered alternative examinations with consideration of financial and physical accessibility.

It was somehow unexpected that only ¼ of doctors (25.8%) offered patients alternative methods of treatment with regard of financial and physical accessibility, in case the infection was proved.
These findings show that doctors express less support towards young patients.

49 35 5.

Summary of results of the survey carried out according to the scenaios According to the separate components sharp differences were found between regions and among different types of medical facilities (0-100%).
It was also determined, that informative-educational work on such topics as sexual restraint, safe sex, etc, among different types of medical facilities were not held equally among visited patients, visiting facility with different reasons.
In order to assess general service and consulting quality of medical facility according to separate components we have used the scale of 5 point (5-very good, 4-good, 3 - average, 2-poor, 1-very bad) according to the frequency detected from the survey (see chapter methodology).

The medical service in female and male RH/SH services were assessed separately.
With the use of above mentioned system in total the medical service in female RH/SH services was assessed as average, and male RH/SH services – as good.

As it was mentioned above, despite significant differences between regions and types of medical facilities in separate component of medical service, in total in towns and in villages, also in different regions and among different types of medical facilities, medical service in female RH/SH services were assessed as average.
On the contrary to female RH/SH services, the differences in male RH/SH services were reflected on regional results.

In Tbilisi male RH/SH services was assessed as good., in other towns – as medium, in villages – as poor.

In Tbilisi and Adjra region medical service was assessed as good, in Kakheti and Mtskheta-mtianeti as poor, and in Shida Kartli as – very poor.

50 36 Summary 1.
50 36 Summary 1.

According to the survey, it was identified that for the majority of both genders of teenagers (78.4%) RH/SH services are physically accessible due to the availability of the signs located on the front of medical facilities.

It was twice difficult to find such services in villages, than in towns.

Significant regional differences were detected.

RH/SH services were found in Mtskheta-mtianeti (100%) and Imereti (95%) more easily, than in Shida Kartli and Kakheti (33.3% and 33.3%).
The signs on female RH/SH services were allocated in every case, and sign on ambulatories only in ¼ of cases, that made difficult to find them.

2.

Inside RH/SH facilities absence of directing signs were more frequent (36.6%), than their absence on the fronts of the facilities (10%).

In villages directing signs inside facilities were in one among every ten cases, in towns – 6 times more often.

The differences between regions and among the different types of facilities were not significant.

3.
3.

For increasing accessibility to RH/SH services for youth, one of the favorable factors is the possibility of appointing the visit in suitable time and day, which was quite low (30.1%).

Scheduling visit beforehand was only in 39.9% of medical facilities and mainly in facilities visited by males.

In majority of rural medical facilities and male RH/SH services (75.2%) young patients didn’t have to wait long (not more than 5 minutes) for medical service.
According to regions, in Imereti patients had to wait for long.

Among different types of medical facilities waiting time was shortest in ambulatories.

Waiting for turn more than once was very rare (4.6%) and mostly was displayed in those facilities (private clinics, private gynecological clinics), where complex examination and services are mostly offered.

4.
4.

In terms of improvement financial accessibility discounts or different tariffs for young patients in RH/SH services were rare (3.9%) and this was concerned only to females living in towns.

Very interesting figures were obtained in Kakheti region, where the frequency of this type of benefits was highest (22.2%).
Also the frequency of giving information about the state programs for free medical services was quite low (7.2%), that mainly can be explained with the reason that these kind of programs are very rare, especially for males.

5.

General condition of facilities, where RH/SH services were llocated, mainly was assessed as “average” (48.4%), more then 1/3 – as “good” and only few as “poor”.

However the difference between facilities located in towns and villages were displayed with extreme categories.
Assessment “good” was four times higher in towns compared to villages, and assessment “poor” was 5 times higher in villages, compared to towns.

It must be mentioned that high frequency of being in poor condition medical facilities are located in Kakheti and Shida Kartli regions (55.6% and 66.7% respectively).

6.
6.

It was determined that in general the cleanness in majority of RH/SH services was in accordance with the assessment of “good” (37.3%) and “very good” (30.7%), mainly in urban facilities for females.

The cleanness in doctor’s room was mentioned with more frequency and manly in towns, compared to villages.

In majority of cases the leanness of dressing of medical personnel was 51 37 appropriate to their profession (96.1%).
The differences according to regions and types of medical facilities were not significant.

7.

In majority of RH/SH services (74.5%) there was a comfortable environment, among them twice more in towns than in villages.

Significant regional differences were found.

The highest indicator was registereded in Imereti (90%) and the lowest in Mtskheta-mtianeti (33%).

As it was expected comfortable environment with highest frequency was present in private clinics and gynecological clinics.
8.OOne of the main conditions for young patient in RH/SH services is confidentiality, that is assessed with the existence of isolated place for consultation, absence of third person on consultation, no possibility of hearing about the problems of other patients while waiting for turn and with the assuarance by medical personnel of keeping confidential information.

Such kind of environment was in ¾ of medical facilities.
The confidential environment was more frequent in urban male RH/SH services, than in villages.

The regional differences were significant.

The best results were obtained in Imereti, the worst in Kvemo Kartli, Kakheti and Mtskheta-mtianeti.

Anonymity (at registrar’s office, during medical service) was kept in more than half cases (57.5%).

It must be mentioned that one of the means of keeping confidentiality is having separate entrance for teenagers and this was not in any surveyed facility.

9.
9.

Attitude of medical personnel at RH/SH services towards patients during the whole visit in majority of cases (97.4%) was polite and friendly, health professionals were greeting patients and when farewelling were offering their assistance in the future (66%).

Cases of condemnatory attitudes towards young patients during their visits due to delicate problems were rare (17.6%).

Mainly it was expressed towards females.


The differences according to regions and different types of medical facilities were not significant.

10.

RH/SH services represent one of the important sources for teenagers in obtaining information and education in this area.

In majority of surveyed medical facilities there were informational- educational materials in waiting room, but mostly these materials were not diverse and no appropriate conditions to be able to read them.

11.
11.

Educating and informing of teenage patients during the consultation or visiting the clinic due to different reasons in such issues as sexual restraint, safe sex, etc.

are not held equally.

Doctors rarely talked about the sexual restraint and safe sex to the teenage patients who visited doctor for termination of pregnancy, though the ones who couldn’t delay the sexual debut are also need to be acquainted with the positive aspects of sexual restraint and safe sex.

12.
12.

Information about medical treatment and all alternative methods of contraception were given by doctors in majority cases, completely – in more than half of cases, and incompletely – with less frequency (39.2%).

The frequency of not giving any information was very low (8.5%).

The level of frequency of giving complete information in towns were higher compared to villages, and the frequency of not giving information was higher in villages.

Significant regional differences were also detected.
The best results were received in Adjara, and data in Shida Kartli, Mtskheta-mtianeti and Kakheti were not promising.

52 38 13.

Regardless significant differences between regions and different medical facilities with regards to separate components, in whole, as well as in towns and villages and different types of medical facilities quality of care at female RH/SH services was assessed as “average”.
In difference to female services, male RH/SH services the differences according to separate components were fully reflected in summative regional results.

The quality of male RH/SH services in Tbilisi was assessed as “good”, in other towns as “average”, in villages as “poor”.

In Tbilisi and Adjara the quality of medical care was assessed as “good”, in Kakheti and Mtskheta- mtianeti as “poor”, and in Shida Katli as “very poor”.
In total the assessment of medical service quality in male RH/SH services was “good”.

53 39 Recommendations Advocate for youth sexual and reproductive health and rights at legislative and executive governmental levels for their protection and promotion: Emphasize on social and medical importance of investments in youth health; Initiating long term governmental policies and programs oriented on youth.
In terms of development of youth friendly RH/SH services and considering the survey results, carry out with healthcare organizers cooperation in following directions: Development of curricula and conduct short-term seminars for healthcare organizers for explaining the essence and importance of youth friendly RH/SH services; The following activities must be promoted by healthcare organizers: In order to increase for youth accessibility to RH/SH services: provide availability of signs on the fronts and inside the buildings, organize the visits in convenient times and days for youth, scheduling the visits beforehand, etc.
; Establish beneficial tariffs for youth medical service in terms of increasing financial accessibility to RH/SH services; Create confidential environment and keep privacy in RH/SH services (registration of patients according to the numbers, hold examination and medical treatment anonymous, ensure isolated room or place for consultations, if possible provide a separate entrance and waiting room, etc.
); Create necessary environment in RH/SH services for informational-educational work with youth (availability of appropriate amount of informational-educational materials and create a proper environment to get acquainted with them).
In order to provide teenagers with high quality medical treatment improve the knowledge of medical personnel through their maximal involvement in seminars devoted to the issues of reproductive and sexual health and youth friendly RH/SH services; Improvement of the qualification of medical personnel must be focused on gaining and improving skills that will help to hold informational-educational work and establish responsible RH/SH behavior; Pay special attention to the establishment of youth friendly RH/SH services throughout Georgia, particularly in villages and in those regions where according to the survey services were found to be below the standards and did not meet the needs of the population.
54 40 References: qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 2005 qalTa reproduqciuli janmrTelobis kvleva saqarTveloSi, UNFPA.Tbilisi, 1999 mozardTa reproduqciuli janmrTelobis kvleva UNFPA.Tbilisi 2002 mamakacTa reproduqciuli janmrTelobis kvleva UNFPA.Tbilisi 2005 1.

2.

3.

4.

5.

UNFPA Framework For Action on Adolescents &Youth 2007.

6.
6.

Research Issues in Sexual and Reproduqtive Health for Low and Middle-Income Countries _- Global forum for Health Research and World Health organization 2007.

7.

Adolescent Friendly Health Services – An Agenda for Change – WHO/CAH/02.14 – World Health Organization, October 2002.

8.

The world reaffirms Cairo: official outcomes of the ICPD at ten review (New York: UNFPA, 2005.

9.

World Leaders Statement in Support of ICPD, 2004.

10.

ICPD Programme of Action, 1994.


11. reproduqciuli janmrTelobisa da reproduqciuli uflebebis sakiTxebi saqarTvelos kanonmdeblobaSi _ UNFPA Tbilisi, 2004.

12.

Demographic Yearbook of Georgia 2003.UNFPA.Tbilisi, 2004.

55 41 Appendix #1 Questionnaire Assessment of Reproductive Health Cabinet Please, carefully read the questionnaire before you start the assessment.

It is essential that you provide answers to all asked questions Fill in the data on your visit.
(Make sure that you indicate the exact time of your visit for further confirmation) Interviewer’s name: Interviewer’s signature: Do you confirm that you visited the reproductive health cabinet?

1.

Yes 2.

No A1.

Interviewer ID: A2.

Date of visit: A3.

Week day: A4, Starting time of interview: A5.

Ending time of interview: A6.

Amount of time spent in Cabinet (in minutes): A7.

Nationality of Interviewer: A8.

Language of interview: A9.

Region A10.


Health facility / / 2007 Mon/ Tue / Wed / Thu / Fri / Sat / Sun : : _________ minutes 1 2 3 4 Maternity house Women consultation center 5 6 Private clinic 7 Family medicine center (Family doctor) Ambulatory Hospital Polyclinic A11.

Type of settlement: 1 - Urban 2 - Rural A12.

Address of health facility Your comments are very important as they are essential for continued staff development.
We appreciate that you are trying your best to provide us with the most detailed information possible, especially in instances when you were not satisfied with the quality of services that were provided during your visit.

6 42 Hidden check Request for consultation A13.

Scenario # Evaluation Questionnaire 1.

Physical availability of the service Q1.

Did you find the reproductive health cabinet to be conveniently located?
Single response Yes......................................................................100 No ........................................................................ 0 (Your comment) ________________________ _________________________________________ _________________________________________ 2.

Financial availability of the service Q3.

When you questioned the health provider did they provide you with information on state programs, which you have right to use free of charge?
Single response Yes..................................................................................................100 No ...................................................................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ 3.

Facility External view of the facility Q7.

How clean was the facility in general?


Very clean .......................................................... 100 Clean .................................................................. 80 Average clean ..................................................... 50 Unclean ............................................................... 30 Very unclean ....................................................... 0 Q8.

Was the doctor’s office where you were consulted clean?
Single response Yes..................................................................................................100 No ...................................................................................................... 0 Your comment) ________________________ _________________________________________ _________________________________________ Q9.

Was there a separate space allocated for a reproductive health service?
Yes..................................................................................................100 No ...................................................................................................... 0 (Your comment) ________________________ _____________________________________ _____________________________________ ______________________________________ Q10.

Were the medical personnel dressed neatly, as medical professionals should be?
Only one answer Yes ................................................................................................. 100 No ....................................................................................................... 0 Comfort Q11.

Was the waiting room and environment itself comfortable for patients?
Yes..................................................................................................100 No ...................................................................................................... 0 (Your comment) ________________________ Q4 Does the reproductive cabinet or family medicine center office have any inscription/sign at the entrance?
Single response Yes, an illuminated sign......................................................100 Yes, not illuminated sign ....................................................100 No, no sign at all ....................................................................... 0 Q5.

Were there any stickers/signs near the entrance indicating the location of the reproductive cabinet?
Single response Yes..................................................................................................100 No ...................................................................................................... 0 Compliance with general standards.

Q6.

How would you assess the condition of the medical facility in general?
Single response Good......................................................................... 100 Fair ............................................................................ 50 Bad.............................................................................................................0 Q12.

Was the lighting in the facility/waiting room adequate for the patients to read informational/ educational materials?
Single response Yes..................................................................................................100 No ...................................................................................................... 0 Q13.

Does the health care facility give the opportunity for young patients to arrange a visit within a suitable time frame?
Yes..................................................................................................100 No ...................................................................................................... 0 Q14.

In your opinion, was the environment suitable to conduct a confidential conversation and receive consultations during your visit?
Single response Yes..................................................................................................100 No ...................................................................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ 7 43 Q15.
Indicate what was in the medical facility from the listed below: Multiple answers are allowed - Beverages, water, tea, coffee - Enough seats - Suitable temperature - Small table for informational leaflets - TV, music, reading materials - Restroom (WC) From 4 to 6 items................................................ 100 2-3 items.............................................................. 50 Less than 2 items ................................................. 0 (Your comment) _______________________ Q16.
Was there a special room in the doctor’s office for patients to have consultation and examinations?

Single response Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ ________________________________ ___ ________________________________ ___ Confidentiality issue Q17.

Is there a separate entrance for young patients?


Yes ..................................................................... 100 No......................................................................... 0 Q18.

Is there a separate waiting room for young patients?

Yes ..................................................................... 100 No.......................................................................................................0 Q19.
Is it possible to schedule the time of the visit beforehand to avoid long waiting time?

Yes ..................................................................... 100 No .....................................................................................................0 Q20.

Was there a confidential environment in the registrar’s office?
Yes ................................................................................................. 100 No.......................................................................................................0 Q21.
Have you been asked by the registrar/ medical personnel to provide with the following data: Multiple answers are allowed ID Name Medical history Health certificate Registration number 3 and more ......................................................... 100 Less than 3 ...................................................................................0 8 44 Q22.

Was the doctor chosen according to the patient request at the registration desk?
Yes......................................................................100 No.......................................................................................................0 Q23.

If not, were the reasons explained to the patient courteously?

Yes......................................................................100 No.......................................................................................................0 Information Q24.
Was the patient asked by the doctor, why he/she chose this facility and what are his/her expectations?

Q Yes......................................................................100 No .........................................................................0 (Your comment)_________________ ______________________________ ______________________________ Q25.

Did the health provider inform you about the terms of payment?

(for consultation, tests, etc)?


Single response Yes, the doctor informed me ......................................... 100 Yes, after my request ............................................................50 No .....................................................................................................0 (Your comment) _______________________ ______________________________ ______________________________ Q26.
Did medical personnel have a name tag, and was the inscription on the doctor’s office door or name tag on the table written with a full name?
Single response Yes......................................................................100 No .........................................................................0 (No comment) ______________________________ Merchandising Q27 Indicate whether the following informational/educational materials were displayed in the waiting room: Broshures and posters on reproductive health Yes........................................................................1 No .........................................................................0 Wall illuminated posters/educational information materials Yes................................................................................. 1 No ................................................................................... 0 Informational/educational video clips on TV monitor Yes........................................................................1 No .........................................................................0 1-3 .....................................................................100 Less than 1 ..........................................................0 (Your comment) ____________________________ _________________________________________ _________________________________________ Q28.
Was it comfortable to get acquainted with informational/educational materials (posters, brochures, response leaflets)?

Single Q34.

Did the doctor say good bye to you regardless of whether the consultation was held or not?
Only one answer Yes......................................................................100 No .........................................................................0 There was no information/educational printed materials N/S (Your comment) _______________________ _________________________________________ Yes, said good bye and suggested his help in case the need arises .......................................................................100 Yes, just said good bye........................................................70 No ...................................................................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ 4.
Service Hospitality Q29.

Did the medical personnel greet you?

Yes..................................................................................................100 No .................................................................................0 Q30.

Was the medical personnel’s attitude towards young patients friendly?
Indicate the relevant answer Yes..................................................................................................100 No ...................................................................................................... 0 (Your comment ___________________________ _________________________________________ Q31.

Did the medical personnel show respect and support to young patients?
Indicate the relevant answer Support Respect Sympathy Attention From 2 to 4..........................................................100 1 or 2....................................................................70 Less than that ......................................................0 (Your comment) _______________________ _________________________________________ _________________________________________ Q32.

Were you treated well throughout the duration of your visit?
Only one answer Yes......................................................................100 No .........................................................................0 (Your comment) _______________________ _________________________________________ Q33.

Was there any kind of condemnatory attitude on the part of a doctor?
Yes..................................................................................................100 No ...................................................................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ Confidentiality/privacy Q35.

Were you guaranteed that your visit would be kept confidential?
Yes, at the beginning of conversation................. 100 Yes, after my question ........................................ 50 No......................................................................... 0 (Your comment) _______________________ _________________________________________ Q36.

Was there any other – third person in the room besides you and the doctor?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment) Q37 Was the environment confidential in the doctor’s cabinet?

Yes ..................................................................... 100 No......................................................................... 0 (Your comment) _______________________ ________________________________ ________________________________ Q38.
If not, did the doctor take into account the request of the patient and make any attempt to create such an environment?

Yes ..................................................................... 100 No......................................................................... 0 (Your comment) Q39.

Was it possible to observe/read any information from the registrar’s/medical personnel c omputer or paperwork?
Only one answer Yes ..................................................................... 0 No..................................................................... 100 (Your comment) _______________________ _________________________________________ _________________________________________ Q40.

Could you listen to confidential information from the conversation of other doctors and patients while waiting your turn or being consulted?
Only one answer Yes ....................................................................... 0 No....................................................................... 100 No other patients around .................................... N/S (Your comment) _______________________ _________________________________________ _________________________________________ 9 45 Q41.

Were you assured that your personal information will be treated confidentially by the doctor?
Only one answer Yes ..................................................................... 100 No......................................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ Convenience Q42.

Did medical personnel try to speak with you in your native language?
Yes ..................................................................... 100 No, did not try ....................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ Q43.

Did a doctor talk to you simply and understandably (without complicated medical terms)?
Yes ..................................................................... 100 No......................................................................... 0 Information Q44.

Where there any special discounts at the particular unit and different fees for younger patients?
Only one answer Yes ..................................................................... 100 No......................................................................... 0 (Your comment) _______________________ _________________________________________ _________________________________________ Q45.

Did the medical personnel recommend an alternative doctor or send you to another doctor?
Only one answer Yes, recommended ............................................ 100 Yes, sent me to another doctor .......................... 100 No........................................................................ 50 (Your comment) _______________________ _________________________________________ _________________________________________ _________________________________________ Q46.

Were you given enough information on alternative ways of treatment and contraception methods?
On all alternative ways Yes ....................................................................... 1 No......................................................................... 0 On all contraception methods Yes ....................................................................... 1 No......................................................................... 0 Informational/educational printouts (brochures, leaflets, etc) Yes........................................................................1 No .........................................................................0 On side-effects of treatment and its contradictions Yes........................................................................1 No .........................................................................0 Were you acquainted with all modern achievements in this sphere?
Yes........................................................................1 No .........................................................................0 3 or more ............................................................100 1-2........................................................................50 Less than 1 .........................................................0 (your comment) _______________________ _________________________________________ _________________________________________ Adequate allocated time Q47.
Did the doctor listen to you carefully and till the end?

Only one answer Yes......................................................................100 No, he/she was too busy.......................................0 No, he/she was often distracted............................0 (your comment) _______________________ Q48.

Did a doctor ask questions to find out about your problem in more detail?
Only one answer Yes......................................................................100 No .........................................................................0 (Your comment) _______________________ _________________________________________ _________________________________________ Q49.

Do you think that the doctor identified precisely what your problem was?
Only one answer Yes, precisely..................................................... 100 I am not sure that he found it out fully ..................50 Did not understood ..............................................0 (your comment) _______________________ _________________________________________ _________________________________________ Q50.

Did your doctor promise to give support to you in solving the problem?
Only one answer Yes......................................................................100 No .........................................................................0 (Your comment) _______________________ _________________________________________ _________________________________________ Q51.

Did you get the impression that the doctor overestimated and made your problem sound worst?
Only one answer Yes......................................................................100 No .........................................................................0 (Your comment) _______________________ _________________________________________ 10 46 Q52.

How much time (in minutes) did the doctor spend with you?

Only one answer Q55.

Generally how satisfied were you with your visit to doctor?
Only one answer minutes An adequate amount of time was spent with me .......... 100 Tried to shorten the visit .................................................50 Tried to get rid of me........................................................0 Waiting time Q53.

How much time (in minutes) did you have to wait for a doctor?
Only one answer minutes Quite satisfied..................................................... 100 Satisfied............................................................... 80 Neither satisfied nor dissatisfied .......................... 50 Dissatisfied .......................................................... 20 Very dissatisfied .................................................. 0 Q56.

Were you asked whether or not you were satisfied with the service and what else could have been done to improve it?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment)________________________ 0 – 5 minutes ......................................................100 5 – 10 minutes .....................................................50 More than 10 minutes ...........................................0 Other Q57.

Please share any other comments Q54.


Did you need to come more than once to receive full service?
Only one answer Yes........................................................................0 No .......................................................................100 (Your comment) _______________________ _________________________________________ about this medical facility _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ ______________________________________N/S 11 47 conclusion Q58.
Now we want to find out about your impressions regarding your visit to doctor.

How you would assess each of the following aspects of the visit?

Question Assess by 10 point scale: From 1-very bad result to 10 – very good result How would you assess your impressions of the services provided to you in the medical facility today?

How reliable/confidential does your consultation seem to you today?

How satisfied were you with the duration of consultation provided to you today?
How convenient and comfortable was the medical service provided to you today?

How would you assess the quality of service/professionalism of medical personnel in the unit where the consultation was held?

How comfortable did you feel during the doctor’s examination?

How convenient was the service and how easy was to use it in the given medical facility?

Would you choose the same medical facility and the same doctor once again if you will need the consultation in future?
Not for the assessment Q59 please, provide any additional comments regarding your visit and which were not covered during the questionnaire.

We would appreciate if you provide comments of other patients; those that you overheard in the facility talking about the medical staff and quality of the services provided.
_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ __________________________________N/S N 12 48 Scenario #1 A 16 years old teenage girl visited medical facility (women’s consultation center, family medicine centre, reproductive health cabinet, etc) and requested consultation with a young female doctor.
When meeting the doctor, she asked to discuss in a confidential environment.

Reason for the visit: Patient doubts whether she can be pregnant.

Patient is unmarried; she had unprotected sexual contact with her boyfriend approximately 3 weeks ago.

At present has delay of 1 week in her menstrual period.
Appendix #2 The goal: maintaining confidentiality with regard of age and marital status of the patient, attitude that medical personnel had towards their patient and assessment of the quality of consultation (the ability of understanding fully the problem, which included the prescription of necessary examinations, providing patients with the information about possible negative consequences of having an abortion and the different methods of contraception, determining the risks of STDs, paying attention to the patients ideas and her involvement in planning for further regimens of medical treatment, and obtaining an adequate level of knowledge of current Georgian legislation).
S1.1 Did the doctor ask the patient what would have been the reaction of the patient, if she turned out to be pregnant ?

Yes........................................................................0 No .......................................................................100 (Your comment) _______________________ __________________________________ _________________________________ S1.2.
Have a doctor suggested (with sympathy or with imperative tone) assistance in involving parents and partner to solve the existing problem ?

Yes........................................................................0 No .......................................................................100 (Your comment) _______________________ __________________________________ __________________________________ S1.3.
Did the doctor informed the patient on risks of complications during other possible abortion, complications of delivery in the teen age?

pregnancy and Yes........................................................................0 No .......................................................................100 (Your comment) _______________________ _________________________________________ _________________________________________ S1.4.
Did the doctor informed about characteristics and conditions of safe and unsafe abortions?

Yes........................................................................0 No .......................................................................100 (Your comment) _______________________ _________________________________________ _________________________________________ S1.5.
Did the doctor informed the patient about the advantages of delaying sexual activity until a person was physically and emotionally mature?

Yes........................................................................0 No .......................................................................100 (Your comment) _______________________ _________________________________________ _________________________________________ S1.6.
Did the doctor informed the patient on and of positive contraception, its ways and methods to use in the future ?

sides safe sex Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ _________________________________________ _________________________________________ S1.7.

Did the doctor inform how and when the pregnancy can begin?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ S1.8.

Did the doctor inform how pregnancy could have been identified and advise to conduct necessary tests ?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ S1.9.

Did the doctor ask the patient whether there were delays in her periods before, or if there were some subjective signs (symptoms) (dizziness, vomiting), which had not been seen before ?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ S1.10.

Did the doctor suggest gynecological examination?


Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ S1.11.

Did the doctor suggest tests to identify tests), or (including confidential STDs whether he/she tried to identify the risks?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ 13 49 S1.12.

Did the doctor asked the patient about her sexual behavior (whether she has regular sexual intercourses, number of partners, etc)?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ Scenario #2 A 15 years old teenage girl visited medical facility (women’s consultation center, family medicine centre, reproductive health cabinet, etc) and requested consultation with young female doctor.
When meeting the doctor, she asked for a confidential environment.

Girl is not married.

Reason for the visit: two days ago patient had unprotected sexual contact and she want to escape possible pregnancy, because she had heard about such possibility.
The goal: keeping the confidentiality with the regard of age and marital status of the patient, the attitude of medical personnel towards patient and assessment of the quality of consultation (the ability of understanding fully the problem, prescription of required examinations, providing patients with the information on possible negative results and consequences of abortion and information about contraception methods, introducing the patient with all types of urgent contraception and describing their effectiveness and other various features, scheduling of the next visit , determining the risks of STDs, paying attention to the patients views and the involvement of patients in planning the further tactics of medical treatment, and level of knowledge of current Georgian legislation).
S 2.1.

Have a doctor suggested (with sympathy or with imperative tone) assistance in involving parents and partner to solve the existing problem?

Yes ..................................................................... 100 No......................................................................... 0 (Your comment)______________________ informed the doctor the patient on possible risks of complications during abortion, pregnancy and other complications of delivery in the teen age ?

S2.2.
S2.2.

Did Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ _________________________________________ _________________________________________ S2.3.

Did the doctor informed about safe and unsafe abortion characteristics and conditions ?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ _________________________________________ _________________________________________ S 2.5.

Did the doctor informed the patient on positive sides of safe sex and contraception, its ways and methods to use in the future ?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ _________________________________________ _________________________________________ _ S 2.6.

Did the doctor inform how and when the pregnancy can begin ?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ S2.7.

Did the doctor suggest gynecological examination?


Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ S 2.4.

Did the doctor informed about advantages of delaying sexual activity until a person was physically and emotionally mature?

S 2.8.
S 2.8.

Did the doctor suggest tests to identify STDs including confidential tests?

or whether he tried to identify the risks?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ _________________________________________ _________________________________________ Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ 14 50 S 2.9.
Did the doctor asked the patient about her sexual behavior (whether she has regular sexual intercourses, number of partners, etc) ?

Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S2.11.

Did the doctor ask patient, when she had menstruation last time?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S2.12.

Did the doctor acquaint the patient with the information on what kind of pills can be used for emergency contraception and their efficiency according to the time passed after sexual contact?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S2.13.
Did the doctor acquaint the patient with the information on what kind of contraception can be used as internal means of contraception such as IUD (intra uterine device) and their efficiency according to the emergency and terms contraceptive methods?

Yes......................................................................100 No .........................................................................0 (your comment) _______________________ use as of S2.14.
Did the doctor explained to patient where she could find such contraceptives (pills, etc.

- at drug store, and IUD (intra uterine device)- at medical facility)?

Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S2.10.
Did the doctor try to find out how much time passed after the mentioned sexual contact?

Yes........................................................................0 No .......................................................................100 (your comment) _______________________ _________________________________________ _________________________________________ S2.15 Did the doctor offer assistance with inserting the IUD (intra uterine device)?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ _________________________________________ _________________________________________ S2.16 Did the doctor explain rules for taking various types of pills and if he/she was sure that the patient correctly comprehended the information?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S2.17 Did the doctor tell the patient about side effects of pills or IUD contraception means?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S2.18 Did the doctor call on the patient for a repeated visit and explain about its necessity timely determine possible pregnancy, taking into consideration that emergency contraception might have proved ineffective?
to Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ 15 51 Scenario #3 A 17 years old teenage girl visited medical facility (female consultation center, family medical centre, reproductive healthcare cabinet, etc) and requested consultation with young female doctor.
When meeting the doctor, she asked for a confidential environment.

Reason for the visit: patient wants to terminate 8 week pregnancy.
The goal: assuring confidentiality with the regard of age and marital status of the patient, the attitude of medical personnel towards patient and assessment of the quality of consultation (the ability of understanding fully the problem, prescription of required examinations, providing patients with the information on negative results of abortion and information about the various methods of contraception, determining the risks of STDs, paying special attention to the patients’ ideas and seeking involvement in planning for various approaches medical treatment, and sharing of knowledge about current Georgian legislation).
In addition, finding out whether or not the doctor tried to determine necessity of abortion.

It is also necessary to determine the degree of involvement in this problem relatives and partner in terms of agreement of “patient”.
If patient decides to have a child then to consider whether or not did the doctor give full information about prenatal surveillance and advised as to the best methods for decreasing the risks related to pregnancy and the understanding the disadvantages of delivery in a teenage period.

S 3.1.

Have a doctor suggested (with sympathy or with imperative tone) assistance in involving parents and partner to solve the existing problem?
Yes ....................................................................... 0 No....................................................................... 100 (your comment) _______________________ S 3.2.

Did the doctor informed the patient on possible risks of complications during abortion, pregnancy and other complications of delivery in the teen age ?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ _________________________________________ S 3.3.

Did the doctor informed about the characteristics and conditions of safe and unsafe abortion?
Yes ....................................................................... 0 No....................................................................... 100 (Your comment) _______________________ S3.4 Did the doctor informed about advantages of delaying sexual activity until a person was physically and emotionally mature?
Yes ..................................................................... 100 No......................................................................... 0 (Your comment) _______________________ S3.5 Did the doctor inform the patient on positive sides of safe sex and contraception, ways and methods as how to use in the future?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S3.6 Did the doctor inform how and when the pregnancy can begin?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ 16 52 S3.7 Did the doctor suggest tests to identify STDs (including confidential tests) or whether she tried to identify the risks of their presence?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S3.8 Did the doctor asked the patient about his sexual activity (whether she is engaged in regular sexual intercourses, number of partners, etc)?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S3.9 Did the doctor try to determine just how unavoidable was terminating the pregnancy?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S3.10 Did the doctor suggest gynecological or any other examination to confirm pregnancy or determine its stage (its term)?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S3.11 Did the doctor acquaint the patient with responsibilities she might face with respect to maternity?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ of risks S3.12 If the patient agreed on retaining pregnancy, but expressed fear that she had heard about high and being complications of child delivery during juvenile age, did the necessity and effectiveness of intensive supervision in teen age and the necessity of receiving such care in order to avoid possible complications?
the doctor explain pregnant to her Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ Scenario #4 A 16-year-old teenage girl visited medical facility (women’s consultation centre, family medicine centre, reproductive health cabinet, etc).
The young woman had given birth to a child two months ago.

She first gave birth to a child at the age of 15.

She did not breast feed the child.

After 3 months she became pregnant again and gave birth to the second baby at the age of 16.

Reason for the visit: patient wants that a suitable means for contraception is selected for her.
At the same time, she worries because her husband would like her to get pregnant again in the nearest future and that is why she requests that her visit remains confidential.
The goal: the assessment of the quality of medical service and consultation (according to needs of “patient” did the doctor gave full information about all the contraceptive methods with their characteristics, paying attention to obstetric anamnesis and needs of the patient, whether the doctor has offered medical examinations, has the doctor tried to involve the husband of the “patient” in problem-solving and did the physician try to provide complete information about the reproductive health, especially about the high risks of pregnancy and the complications of delivery as a teen, the necessity of maintaining intervals between the birth of children, and whether the doctor took into consideration the request of the patient to keep the visit confidential, even when the patient is in official marriage).
S4.1 Did the doctor suggest gynecological examination?

Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S4.2 Did the doctor suggest tests to identify STD-s (including confidential tests), or whether he tried to identify the risks?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ S4.3 Did the doctor suggest patient to bring her husband to medical facility?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S4.4 IF the patient strongly objected such possibility, did the doctor help her to choose a contraceptive?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ interval between pregnancies S4.5 If accompanied by a husband, did the doctor explain to both husband and wife that a 2- year is desirable for a woman and child’s good health?
Yes........................................................................0 No .......................................................................100 (your comment) _______________________ _________________________________________ _________________________________________ S4.6 Did a doctor introduce the patient with different methods of contraception, their effectiveness, and complications?
effects side Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S4.7 Did a doctor use illustrative materials?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ 17 53 S4.10 Did a doctor explain to the patient where she can buy contraception pills or whether or not the medical institution has an adequate supply of them (free-of-charge) and available for the patient?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S4.8 Did a doctor take into consideration peculiarities of different periods (stages) of a recent birth-giving) woman’s (absent- adaptability, woman’s character minded, etc.)
when considering the various means of contraception to recommend?

(e.g.

life Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S4.9 When choosing contraception, did a patient and a doctor come to a joint decision, or was it the doctor who made a decision?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ Scenario #5 A 18 year old teenage boy visited a medical facility (hospital, family medicine centre, reproductive health cabinet, etc) and requested confidential consultation with a young male doctor.
Reason for the visit: Three days ago, while being under influence of alcohol, he had unsafe sexual intercourse with a newly acquainted woman.

He is afraid of a high risk of being infected with HIV/AIDS, or some other sexually transmitted diseases.
The goal: to provide an assessment of the quality of medical service and consultations (how well has the doctor performed history taking, did he prescribed an appropriate examination or tests, did the physician introduced patient with the potential risks of becoming infected with STDs and how at early stages various STDs not be testable for lack of antibodies and what were the positive aspects of sexual restraint until marriage as well as the negative consequences of engaging in casual sexual relations, what were the basic principles of safe sex, and was the alternative methods of the diagnosis and treatment based on physical location and financial accessibility) provided to the patient.
S5.1 Did the doctor inquire about presence of any symptoms?

Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S5.2 Did the doctor suggest undergoing of testing or examination?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ S5.3 Did the doctor inform the patient about possibility of anonymous examination for HIV/AIDS virus or other sexually transmitted diseases?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ S5.6 Did the doctor introduce the patient with various methods of safe sex?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ 18 54 S5.4 Did the doctor explain that in such a short period of time, symptoms of such diseases couldn’t be identified because of lack of antibodies, though it does not exclude the chance that the person was infected but it could not be detected?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S5.5 Did the doctor the patient on inform HIV/AIDS or any other sexually transmitted diseases, about duration of the latent period and what was the negative impact on the person’s health, etc?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ S5.7 Did the doctor explain optimal terms for examination on various infections and suggest alternative examinations by taking into consideration financial and physical conditions of the patient?
Yes......................................................................100 No .........................................................................0 (your comment) _______________________ _________________________________________ _________________________________________ S5.8 In case of positive test result, did the doctor offer the patient alternative methods of treatment, taking into account financial and physical accessibility?
Yes ..................................................................... 100 No......................................................................... 0 (your comment) _______________________ _________________________________________ _________________________________________ 19 55 56 Survey on Youth Friendly Reproductive Health Services in Georgia 2007 RHIYC Office 28, Abashidze street, Tbilisi, Georgia, 0179 Tel/fax (+995 32) 231 977 www.foryouth.ge www.4uth.ge www.4uth.net www.unfpa.org.tr/georgia