Authors: Kebede Wegi Feyisa, Negalign Berhanu Bayou, Yibeltal Siraneh, Bekele Wegi Feyisa
Categories: Research, Evaluation, Implementation, Adolescents, Youth, Primary healthcare, Oromia, Ethiopia
Source: Reproductive Health
Authors: Kebede Wegi Feyisa, Negalign Berhanu Bayou, Yibeltal Siraneh, Bekele Wegi Feyisa
In Ethiopia, adolescents and youth continue to experience a high burden of morbidity and mortality related to reproductive health problems. However, the implementation of the adolescents and youth health program in Woliso Town has not yet been evaluated. Therefore, this study aimed to evaluate the process of the program implementation in the primary healthcare facilities of Woliso Town, Oromia Regional State, Ethiopia.
A convergent parallel case study design with a formative evaluation approach was employed from May 21 to June 20, 2023. The evaluation focused on three key the availability of required resources, the compliance of healthcare providers with recommended practices, and the satisfaction of service users — measured using a total of 30 indicators. Data were collected from 411 adolescents and youth through exit interviews. Additionally, direct observations of service delivery, resource inventory, and key informant interviews were conducted. Quantitative data were analyzed using descriptive statistics and multivariable linear regression methods. A p-value of < 0.05 and a 95% Confidence Interval (CI) were used to determine statistically significant factors associated with adolescents’ and youth’s satisfactions. Qualitative data were transcribed in the language of the interview, translated into English, coded, and analyzed thematically. The overall process of the program implementation was evaluated based on predetermined judgment criteria.
The overall process of adolescents and youth health program implementation was 69.6%, with contributions from resource availability (81.1%), healthcare providers’ compliance with the guidelines (51.3%), and adolescent and youth satisfaction (75.7%). Factors associated with adolescents and youth satisfaction were being served at a youth center (β = 0.084, 95% CI: 0.049, 0.119); having previous experience with adolescents and youth health services (β = 0.031, 95% CI: 0.004, 0.058); getting the needed service free of charge (β = 0.060, 95% CI: 0.029, 0.090); and obtaining all the services they demanded (β = 0.099, 95% CI: 0.065, 0.132).
The overall process of adolescents and youth health program implementation was evaluated to be fair. Healthcare providers demonstrated low compliance with the adolescents and youth health service guidelines. To improve the process of adolescents and youth health program implementation and enhance the satisfaction of service adolescents and youth, it is recommended that the concerned stakeholders and health facility managers need to explore alternative financing mechanisms to ensure these services are provided either free of charge or at reasonable prices considering the income level of the adolescents and youth. Furthermore, strengthening healthcare providers’ adherence to the national guidelines, and ensuring the availability of all essential services across health facilities are of paramount importance to improve adolescents and youth satisfaction, thereby increase service utilization.
The role of chance, information bias, and social desirability bias is likely, as adolescents and youth were interviewed within the health facility compound, which might have led to an overestimation of the findings.
The online version contains supplementary material available at 10.1186/s12978-025-02144-5.
Adolescence and youth are considered as critical stages in human development. The World Health Organization (WHO) defines adolescents as individuals aged 10–19 years and youth as individuals aged 15–24 years [1]. Globally, there are over 1.8 billion adolescents and youth, with 90% residing in developing countries [2]. In Africa, adolescents and youth accounts for 31.8% of the total population [3]. Similarly, in Ethiopia, adolescents and youth constitute about 33% of the country’s population. Adolescents and youth play a vital role in shaping the social, economic, and political landscape of the country. Hence, with appropriate investments in place to safeguard and promote their health and well-being, adolescents and youth can significantly contribute to the country’s development efforts [4].
Despite the huge number of adolescents and their vital contributions to the development and future trajectories of the countries, they remain highly vulnerable to various health related problems. For instance, in 2019 alone, more than 1.5 million adolescents and youth died globally, mainly due to preventable or treatable causes [5]. Over the last five decades, there has been minimal improvements in adolescents and youth health in African countries. Additionally, risky behaviors in adolescents and youth have significant contributions to the global burden of diseases [6]. Compared to other region of the world, Africa remain highly affected continent by the number of adolescents and youth suffered from health-related problems. In 2019, adolescents’ mortality rate in Africa was nearly thirteen times higher than in high-income countries, and over seven times higher for youth during the same period [5]. Likewise, in Ethiopia, adolescents and youth continue to suffer from a high burden of morbidity and mortality associated with reproductive health problems [7]. In this regard, adolescents and youth die from these health problems every year, with maternal death being the main contributor (17–29%) to adolescents and youth death [8].
Young people are disproportionately vulnerable to sexual and reproductive health (SRH) problems such as unwanted pregnancy, unsafe abortion, and sexually transmitted infections (STIs), including Human Immunodeficiency Virus (HIV). According to the Ethiopian Demographic Health Survey (EDHS) 2016 report, about 5.4% of sexually active urban females and 3.2% of sexually active rural women were suffered from STIs in the year preceding the survey. Of the 15,000 new HIV infections estimated, about 67.0% of the infections were occurred in the age group below 30 years during the same period. The estimated youth mortality rates were 11.6 deaths per 1000 population during that period [9]. According to the Ethiopian Mini Demographic Health Survey 2019, the median age at first birth was decreased to 18.7 years from 19.0 years in 2005, 19.2 years in 2011, and 2016 EDHS [10].
Despite their high venerability to various health problems, adolescents and youth are usually mistakenly perceived as healthy and as if they are not in need of special health services [11]. On top of that, lack of confidentiality, gender mismatch between healthcare providers (HCPs) and adolescents and youth, and fear of embarrassment undermine the extent of service utilization by adolescents and youth [12]. The mentioned facts clearly demonstrate that adolescents and youth health programs require appropriate adjustments to improve service utilization among adolescents and youth. This may include increased privacy and confidentiality, the use of neutral language (e.g., AYHSs) to reduce stigma, and employing specially trained HCPs who can comfortably communicate on sensitive topics [13].
Adolescents and youth health services (AYHSs) are services that are easily accessible, equitable, comprehensive, efficient, acceptable, and appropriate for young people. These services encompass counseling, family planning, voluntary counseling and testing (VCT) for HIV, and treatment of sexually transmitted infections (STIs). In addition, AYHSs address health issues related to nutrition, mental health, substance abuse, non-communicable diseases, intentional and unintentional injuries, various forms of violence, and risks and vulnerabilities associated with disability [4, 14].
The mentioned fact reveals that adolescents and youth services delivery needs to be strengthened. To this effect, availability of the required resources and HCPs’ compliance with the national guideline are critically important. Nonetheless, the status of the adolescents and youth health program implementation in the Woliso Town primary healthcare facilities (PHFs) has not yet been evaluated. Therefore, this study aimed at evaluating availability of resources needed, HCPs’ compliance with available guidelines and determining adolescents’ and youth’s satisfaction level to AYHSs and associated factors in Woliso Town PHFs, Oromia regional state, Ethiopia. The findings of the study contribute an important knowledge to the literature, and provides evidence for healthcare facility managers and other stakeholders for improved strategies to ensure effective implementation of AYHSs.
A facility-based convergent parallel mixed-method case study design was used to evaluate the process of the adolescents and youth health program implementation in public health facilities (PHFs) in Woliso Town, Oromia Regional State, Ethiopia. The evaluation was conducted from May 21 to June 20, 2023. Qualitative and quantitative data were collected concurrently, and used in evaluating the process of adolescents and youth program implementation.
Woliso Town is located 114 km southwest of Addis Ababa, the capital city of Ethiopia, on the main road leading to Jimma Town. It is the capital of the Southwest Shewa Zone and consists of four administrative kebeles1. According to data obtained from the Woliso Town Health Office, for the 2022/2023 population projection, the number of young people aged 10 to 24 was 22,863—of which 11,431 were aged 10 to 19 and 13,444 were aged 15 to 24. The Adolescent and Youth Health (AYH) program has been implemented at the two Woliso Town health centers (HCs) and the youth center (YC) only. This evaluation was conducted in all the three health facilities (HFs) implementing the program in Woliso Town.
The study population for the evaluation included selected adolescents and youth who visited the selected HFs during the evaluation period, the head of the Town Health Office, the AYH focal person, primary healthcare unit directors, the YC program manager, healthcare providers (HCPs), and AYHS-related documents.
A formative evaluation approach guided by logic model was used, as the primary purpose of this evaluation was to provide information for program improvement. The evaluation dimensions—resource availability, compliance, and satisfaction—were drawn from the WHO standards and measured using a total of 30 indicators adapted from the national AYH strategy. The availability of resources was assessed using 11 indicators to determine whether the physical structures, human resources, infrastructure, medical equipment, guidelines, recording and referral formats, drugs, and supplies required for the program were available in the HFs. The compliance of HCPs was also assessed using 9 indicators by measuring the level of implementation of AYHSs in accordance with the Ethiopian AYH guidelines. Moreover, adolescents’ and youth’s satisfaction were measured using 10 indicators, each rated on a five-point Likert scale (1 = strongly dissatisfied, 2 = not satisfied, 3 = neutral, 4 = satisfied, and 5 = strongly satisfied). Indicator weights refer to the importance assigned by stakeholders to each selected indicator prior to the evaluation, based on its relevance. Indicator scores were calculated using the following
\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \mathrm{Indicator};\mathrm{score};=;\left(\frac{\mathrm{Observed};\mathrm{number};\mathrm X;\mathrm{Indicator};\mathrm{weight}}{\mathrm{Expected};\mathrm{number}}\right)
A matrix of analysis and judgment criteria was developed by combining rational and empirical approaches, involving both key program stakeholders’ consensus and a review of AYHS guidelines. Weights were given to each dimension and indicator based on their relative importance in the evaluation. The cutoff points for judgment were defined as >85% = very good, 75–84.9% = good, 60–74.9% = fair and < 60%= poor [15]. ### Sampling method and sample size The single population proportion formula was used to calculate the required sample size for the client exit interview, considering a 49.1% proportion of adolescents and youth satisfaction with AYHSs from the study conducted in Arba Minch Town [16], 0.05 margin of error, and a confidence interval of 95% \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ (z\;\alpha/_2=\;1.96) $$\end{document}. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \mathrm n\;=\;\frac{\left(\mathrm Z\;\mathrm \alpha/2\right)^{2\;}\left(\mathrm p\right)\;\left(1-\mathrm p\right),}{\mathrm d^2}\;\;\;\mathrm n=\frac{\left(1.96\right)^2\;\left(0.491\right)\;\left(0.59\right)}{0.05^2}\;\;\mathrm n=384 $$\end{document} Where P = Percentage of adolescents and youth assumed to be satisfied with \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \mathrm{AYHSs}\;=49.1\%\;\mathrm d=\mathrm{margin}\;\mathrm{of}\;\mathrm{error}\;5\% $$\end{document}, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\mathrm Z}_{\mathrm a/2}=\;\mathrm{Standard}\;\mathrm{normal}\;\mathrm{at}\;95\;\% $$\end{document} confidence level (1.96). We had considered a 10% non-response rate, making the final sample size 422. The calculated sample size was proportionally allocated to each HF based on the estimated number of service users during the study period, using data from same month in the previous year. A systematic sampling technique was used to select study participants from each HF, with the sampling interval determined from the estimated number of adolescents and youth who received services within a month (1,027) in the selected HFs (K = 1,027/422 ≈ 2.43). The first client/patient was selected by the lottery method, and then every 2^nd^ client/patient^2^ was sampled. In addition to quantitative survey of adolescents and youth, a total of twelve key informant interviews (KIIs) were conducted with the head of the Town Health Office, the Town AYH focal person, four HCPs from HFs, program manager of YC, two primary healthcare unit directors from the two HCs, and three adolescents and youth, considering the saturation of the information. Qualitative data were collected to ensure that the information obtained adequately addressed the evaluation questions and objectives. The Standardized United States Agency for International Development (USAID) observation guideline recommends 3–5 observations per HCP [17]. For this evaluation, eight HCP–patient/client interactions were observed consecutively for each HCP. Since there were four trained HCPs assigned to the AYH clinics across three HFs, a total of 32 observations were conducted—8 from each HC and 16 from the YC. To minimize the Hawthorne effect, the first three observations per HCP were dropped. As a result, 20 observations were included in the final analysis. In addition, a resource inventory was conducted for all three HFs. All patients’ charts that were included in the observation, and HFs’ reports were reviewed. All related documents, registrations, and adolescents and youth who utilized AYHSs at study area during the evaluation period was included in the evaluation. However, documents with incomplete information were excluded. ### Data collection tools and data collection procedures Data collection tools were adapted from AYHS guidelines and various relevant literature [4, 5]18– [20]. Structured questionnaire was used to collect quantitative data from adolescents and youth, while semi-structured questionnaire was used for key informant interviews. Key informant interviews were collected in Afan Oromo, with the support of audio recordings and note-taking simultaneously. Interviewer guiding probes were used to clarify and expand the key informant’s responses. The recorded audio files were transcribed and translated into English. To ensure the quality of the collected data, three experienced enumerators with Bachelor of Science and one supervisor were recruited and trained before deployed to data collection. Moreover, the recruited enumerators are from outside the study area to ensure personal views are not included. With regard to structured survey, enumerators administered the questionnaire to assess adolescents’ and youth’s satisfaction with the provision of AYHSs. A separate space was provided for conducting the adolescents and youth exit interviews. The reliability coefficient (Cronbach’s alpha) of the adolescents and youth satisfaction scale was 0.879, indicating high internal consistency. In addition, direct observations were conducted while HCPs delivering services. Hence, the study provided nuanced evaluation of the process of adolescents and youth health program implementation in the study areas employing different methods complementary to each other. ### Definitions of key terms #### Essential drugs (22 drugs) Essential drugs include combined oral contraceptive pills, emergency contraceptive pills (post-pill), injectable contraceptives, implants, condoms, ceftriaxone, spectinomycin, ciprofloxacin, azithromycin, metronidazole, doxycycline, intravenous fluids, paracetamol, diclofenac, amoxicillin, cotrimoxazole, glibenclamide, salbutamol, omeprazole, diazepam, magnesium sulphate, and vaccines (HPV, tetanus, and diphtheria [Td]). #### Guideline The AYHS guideline that was developed by the Ethiopian Federal Ministry of Health in 2017 [21]. #### Timely report An AYHSs report that all contents were completed without omission and submitted to the respective facility according to the Ethiopian reporting period ((23th −26th of the reporting month, E.C.), from April 2022 to March 2023). #### Hawthorne effect Refers to the increase in the performance of individuals who are observed, monitored, and given attention by researchers or supervisors [22]. #### Service users Adolescents and youths who used AYHS packages at a given HFs during study period. ### Data management and analysis Quantitative data was collected using Kobo toolbox, checked by data collectors before the finalized data were sent to the server. The data were then exported to SPSS version 26 to prepare it for analysis. Descriptive statistics—including means, standard deviations, frequencies, and percentages—were calculated for demographic variables and presented in text and tables. Adolescents’ and youth’s satisfaction score was calculated using the validated percent mean actual value minus potential minimum divided by potential maximum minus potential minimum [23, 24]. Using this continuous scale, linear regression analysis was conducted to determine the independent predictors of adolescents’ and youth’s satisfaction score. Variables with a p-value less than 0.25 were entered into the final model. Subsequently, multivariable linear regression analysis was performed to identify the determinants of adolescents’ and youth’s satisfaction. Finally, variables with a p-value less than 0.05 in multivariable linear regressions were considered significantly associated with adolescents’ and youth’s satisfaction. Checking the assumptions of the multiple linear regression is of paramount importance for obtaining efficient estimates. Hence, the assumptions of multiple linear regressions were checked using appropriate tests. The independent variables included in the model explains about 39.4% of the variation in the dependent variable (R² = 39.3%). The normality of distribution was examined by observing a histogram with a superimposed normal curve and a normal P-P Plot. Multicollinearity was assessed using variance inflation factor (VIF) and tolerance, with no signs of distortion from outliers (maximum VIF = 2.624, minimum tolerance = 0.381, and maximum value of Cook’s distance = 0.018). The spread of residuals appeared fairly constant and independent (Durbin Watson = 1.754). Linearity was checked by scatter plot. The results indicated that all assumptions were met. Qualitative data from notes and audio recordings were transcribed by Afan Oromo (language of the interview) within 24 h of interviews and then translated into English for analysis. First, the translated data were coded into different codes. Each code was grouped into different categories, which were then organized into themes. The data were then analyzed manually using thematic analysis technique, and the results were narrated according to the respective dimensions. ### Data quality assurance The questionnaire was prepared in English, translated into Afan Oromo, and then back-translated into English by another language expert to ensure consistency. A pre-test was administered on 21 adolescents and youth in the Ameya district. Based on the pre-test findings, the final version of the tools was revised before the actual data collection. A one-day training was provided to data collectors and supervisor on the evaluation objectives, data collection tools, techniques, and ethical issues. Additionally, a brief orientation was given on how to collect data using Kobo toolbox and how to send finalized data to the server prior to starting actual data collection process. Data were monitored on the server by the lead author, and immediate feedback and corrective actions were provided to the data collectors. To ensure prolonged engagement between the investigators and key informants, appointments were scheduled for key informant interviews. The preliminary findings were presented to peers for input and feedback (peer debrief). Triangulation was conducted through the use of different key informants at various sites and the use of multiple data collection tools. ### Ethical consideration Ethical clearance was obtained from the Institutional Review Board of the College of Health Sciences, Jimma University (Ref. No. JUIH/IRB/436/23). Informed consent for participation and audio recording were obtained from each participant after providing a clear explanation of the evaluation’s objective. Participants were assured of their right of refuse or withdrawal from the interview at any time. Names and other personal information that can violate the confidentiality of the respondents were not collected or recorded. All notes and audio recordings were kept confidential. ## Results ### Availability of resources In both HCs, AYHSs were provided in a separated AYH clinic (room). However, entrance and exit gates were the same for adolescents and youth in all HFs. Chairs, tables, examination beds, functional doors and windows, electricity, hand washing facilities, and waste bins were available in all AYH facilities. Only HC N*o*1 and YC had a computer with internet access and a stretcher in their AYH facility. Both the adult weighting scale and height meter were available in the YC, while only an adult weighting scale was available in the AYH clinic of HC N*o*2. Unlike the other AYH clinics, neither an adult weighting scale nor a height measure was available in AYH facility of HC N*o*1. The reason reported for their absence was an inadequacy of supplies and budget. Key informant interview results indicated that the way HFs were constructed and the available spaces were not conducive to provide AYHSs in a manner that meets the needs of adolescents and youth. Card, drug dispensary, and laboratory rooms were not separated for adolescents and youth. The waiting areas at both HCs—especially at HC N*o*1 AYH facility —were also found to be uncomfortable and might have undermined the required privacy of adolescents and youth seeking AYHSs. “O*ur HF was not constructed according to the required standards for providing AYHSs. That means*,* we are offering AYHSs in AYH clinics prepared from the rooms we already have. So*,* it may not be comfortable or suitable for delivering services in the way adolescents and youth need. Solving these problems requires more effort*,* as it cannot be addressed at the HC or Town Health Office level. Since we don’t have enough budget*,* we cannot meet the necessary infrastructure requirements. There is also a shortage of supplies from both government and non-government organizations.”* *[35-years-old male, facility head].* *“Waiting area (HC N**o**1 AYH clinic) is adjacent to other service delivery rooms. Therefore*,* many patients walk around there”* [21 years old female, service user]. Training HCPs on AYHSs is important to improve the program implementation as per the standards. In this regard, only six HCPs were trained on most of the minimum adolescents and youth service delivery packages across the three HFs. What is more concerning is that only four of them are constantly assigned and providing AYHSs in the HF's AYH clinics. We further investigated why only one trained HCP on AYHSs is providing the services per HC. We find that shortage of human resources is the primary reason for not assigning adequate and trained HCPs. The number of HCPs trained and the types of AYHS packages upon which they received training are provided in Table 1. *“… Two HCPs were trained from each HC. We are providing the service through HCPs trained on most of the AYHS packages.”* [48-years-old male, AYH focal person]. *“In our HC*,* we have permanently assigned one trained HCP to the AYH clinic. Because*,* the number of HCPs we have is much less than the work they are providing (incomparable). However*,* when assigned HCP is absent*,* the other trained HCP provide the service at the clinic. We need more HCPs.”* [34-years-old male, facility head]. Table 1Number of HCPs trained on the minimum service delivery packages at AYH clinics, Woliso town primary health facilities, Oromia, Ethiopia, 2023Health facilityNo. of HCPs working in AYH clinicNumber of HCPs trained by type of servicesAYH *N* (%)PMTCT *N* (%)SAC and PAC*N* (%)CFP *N* (%)PITC *N* (%)STI *N* (%)LAFP *N* (%)HC N*o*122(100)1(50)2(100)2(100)2(100)1(50)2(100)HC N*o2*22(100)1(50)2(100)2(100)0(0)1(50)2(100)YC22(100)1(50)2(100)2(100)1(50)2(100)2(100)Total66(100)3(50)6(100)6(100)3(50)4(60)6(100)*AYH* Adolescent and youth health, *PMTCT* Prevention of mother to child transmission, *SAC* and *PAC* Safe abortion care and Post abortion care, *CFP* Comprehensive family planning, *PITC* Provider-initiated testing and counseling, *STI* Sexually transmitted infections, *LAFP* Long-acting family planning, *HWs* Health workers, *N* is number In addition to HCPs, availability of resource required for providing AYHSs is crucial. Resource inventory showed that the percent of essential drugs available without stockouts in the last six months (December 2022- May 2023) are as HC N*o*1–86.4%, HC N*o*2–81.8% and YC – 45.5%. Essential drugs such as combined pills, post pills, injectable contraceptives, implants, condoms, metronidazole, doxycycline, intravenous fluids, and diclofenac were available in all three HFs during the last six months preceding the survey period. Furthermore, paracetamol, amoxicillin, cotrimoxazole, glibenclamide, salbutamol, omeprazole, magnesium sulphate, and vaccines (TD (tetanus and diphtheria) and HPV) were available only in HC N*o*1 and HC N*o*2. On the other hand, spectinomycin and diazepam were not available in any of the three HFs. However, azithromycin was unavailable in HC N*o*1 and YC, doxycycline was unavailable in HC N*o*2, and ceftriaxone was unavailable in YC on the inventory date. Regarding the availability of necessary equipment to provide the required AYHSs, all HFs have functional sphygmomanometers, stethoscopes, thermometers, cleaning tools (broom, scrub, brush, cloths, etc.), scissors, needle holders, syringes, intrauterine contraceptive device insertion kits, and surgical and sterile gloves in their AYH clinics. However, pregnancy and HIV/AIDS test kits were not available in all AYH facilities. For pregnancy and/or HIV/AIDS testing, service users are referred to the regular laboratory room. Moreover, HIV test kits were not available in YC during the study period. *“…We (YC) receive drugs and medical supplies from our partners and government organizations. After HIV/AIDS test kits have changed*,* the Woliso Town Health Office has not provided us the new test kits even though I have repeatedly asked.”* [36-years-old male, facility head]. According to information obtained from key informant interviews, the shortage of the above drugs and medical supplies was due to limited availability at the Ethiopian pharmaceutical supply agency and private pharmaceuticals for both HCs, compounded by a budget shortage. In contrast to HCs, the shortage at YC was attributed to the reduction of service delivery packages to certain sexual and reproductive health services. *“We (HC) fill out a Report and Request Form (RRF) for program drugs every two months and summit it to the Ethiopian Pharmaceutical Supply Agency (EPSA). Program drugs are supplied by EPSA. We purchase other drugs and supplies through healthcare financing using internal revenue and the regular budget*,* sourcing from EPSA*,* Biftu Adugna*,* and private pharmaceuticals. However*,* some drugs and medical supplies are not available on the market. Budget shortage is also another barrier.”* [34-years-old male, facility head]. “*Previously*,* we (YC) provided services like antenatal care*,* delivery*,* postnatal care*,* diagnosis and treatment of sexually transmitted diseases*,* and HIV AIDS testing and counseling services. Currently*,* we are no longer providing antenatal care*,* delivery*,* and postnatal care. In the case of some sexually transmitted diseases*,* I write drug prescriptions to external pharmacy. We do not use some of the essential drugs you mentioned.”* [30-years-old male, HCP]. Woliso Town HC N*o*1 and YC have signboards where they indicate the types of service available at their AYH clinics. However, Woliso Town HC N*o*2 AYH clinic does not have a signboard where information about AYHSs are provided. Our result also indicates that there was a shortage of leaflets, posters, and binaries in the waiting area of both HCs’ AYH clinics. This shortage was due to the lack of donations, especially from non-government organizations, and insufficient attention from HF managers and staffs. In contrast, we observed that YC have adequate amount of IEC materials covering various sexual and reproductive health topics. “*We (HC) announce AYHSs by communicating with adolescents and youths in the community*,* schools and HC. In our HC*,* we have not yet used posters*,* leaflets*,* or binaries. In the past*,* non- government organizations*,* especially IPAS*,* donated posters and Vamplets. However*,* IPAS has left our HC since 2020*,* and there is now a shortage of these information and education materials.”* [43-years-old male, HCP***]***. All AYH clinics have guidelines for syndromic management of sexually transmitted diseases, comprehensive abortion care, family planning, HIV/AIDS, and infection prevention case management. However, we observed that none of them have the current adolescents and youth health (2021–2025) strategy. We also observed that standardized integrated AYHS registration was available only at YC. “*We have guidelines for syndromic management of sexually transmitted diseases*,* comprehensive abortion care*,* family planning*,* HIV/AIDS*,* cervical cancer screening*,* and infection prevention. I have received training on all of these guidelines.*” *[38-years-old female, HCP].* The process of the AYH program implementation in terms of program resource availability was measured to be 81.1%, which is good based on the judgement parameters. Details of the judgment parameters used in the evaluation are provided in Table 2. Table 2Judgment on availability dimension in the implementation evaluation of AYH program in Woliso town primary health facilities, Oromia, Ethiopia, 2023Indicators (11)EOWSAJPAvailability of isolated AYH clinic333.03.0100Very goodAvailability of at least one trained health care provider (s) assigned to AYH clinic333.03.0100Very goodAvailability of AYHS strategy (2021–2025) on the day of assessment in AYH clinic303.00.00.0PoorProportion of essential drugs without stock-out in the last 6 months22163.02.172.0FairProportion of FP supplies without stock-out in the last six months51003.03.0100Very goodAvailability of functional pipe water in AYH clinic332.12.1100Very goodAvailability of four vital sign measurement equipment at each AYH clinic333.03.0100Very goodAvailability of at least one IEC materials in/around AYH clinic332.12.1100Very goodAvailability of functional laboratory services333.03.0100Very goodAvailability of integrated AYHS registration312.40.833.3PoorAvailability of external referral formats in AYH clinic332.42.4100Very goodOverall availability of AYH program resources30.024.581.8GoodNote: *E* Expected (from each AYH clinic), *W* Weight, *O* Observed, *S* Score ((observed X weight)/Expected), *A* Achievement in percentage ((S/W) * 100), and *JP* Judgment ParameterJudgement >85% = very good, 75–84.9% = good, 60–74.9% = fair and < 60%= poor ### Compliance with National adolescents and youth health guidelines We have conducted personal observations to evaluate the implementation of AYHS in accordance with the national adolescents and youth health guideline. We have observed five service users at each HC and ten service users in YC regarding the implementation of family planning and HIV counselling and testing services. Similarly, for sexually transmitted infections, interaction between five service users and HCPs were observed at each HF. Our observations revealed that none of the HCP wore identification badges, and only for one service user, HCP introduced himself in order to build a good rapport. About two-thirds (65.0%) of service users were called by their name during service delivery. Regarding the privacy and confidentiality, our observations showed that none of the service user was assured about confidentiality. However, the history of all the service users was taken in a private setting (in a closed door, HCP leaning toward the service users and without interruption), using language they understand. We have also observed that medical terminologies were avoided (Table 3). Table 3Compliance of HCPs with assessment criteria in Woliso town primary health facilities, Oromia, Ethiopia, 2023Activities to be performedPerformed at AYH clinics(*N* = 20) Frequency (%)Smiling and welcoming tone17(85)Greeting service users with respect13(65)Self-introduction to service users1(5)Calling service users by their name13(65)History taking in privacy (closed door and leaning to client/patient)20(100)Respectful and understanding18(90)Use words that service users can understand (avoid medical terms and use language client know)20(100)Ask one question at a time20(100)Record all information related to service on service users’ chart19(95) Regarding family planning services, none of the service user were asked about their knowledge, intentions, or concerns related to family planning in order to assess their level of understanding, experience, and intentions. Only one service user (5.0%) was informed about the availability of condom and injectable family planning methods. Implants were the most frequently advised contraceptive method, mentioned in 35.0% of cases. For most service users (65.0%), family planning choices were specific and free from the moral judgments of HCPs. Most service users received the method they requested, rather than being informed about the advantages and disadvantages of the available family planning options. Only one service user was informed about the advantages and disadvantages of the requested family planning by HCP. At HC N*o*1 AYH clinic, service users primarily received reproductive health services such as family planning and abortion care. However, most of the service users seeking treatment for general illness were treated at adult outpatient department. In contrast, at HC N*o*2 AYH clinic, service users received both treatment for general illness and abortion services. Most of service users who came for family planning service were served at general family planning outpatient department alongside other age groups (above 24 years). This was due to an imbalance between the number of trained and assigned HCPs and range of services to be delivered. Similarly, at YC, adolescents and youth receive services alongside individuals from older age groups (above 24 years). “*HC structures allows only one HCP for the AYHS position. How can one person serve 33.0% of our catchment population*,* considering that adolescents and youth account for 33.0% of Ethiopia’s total population*,* and address all aspects of their health needs? The available policy and resources required to implement it do not align. Even the number of trained HCPs is not enough. You can’t implement this with the current available resources—especially human resources.”* [35-years-old male, HCP]. *“… I know that adolescents and youth are individual aged between 10-24-years range. However*,* we also provide services to other age groups (above 24 years)”* [38-years-old female, HCP]. The observation result showed that none of the service users were counseled on non-communicable diseases. Regarding counseling about nutrition, only one service user (at YC) received counseling on the nutrition. HIV/AIDS testing was conducted for only one service user (5.0%) at the HC N*o*2 AYH clinic. At both HCs, service users did not participate in planning, monitoring, and evaluation of health services. Moreover, they were not participated in decision making regarding their own care or other appropriate aspects of service provision. The reason given for this was that the HCs managers had not planned to involve them. In contrast, at YC, service users participated in program implementation and performance review. *“We did not involve adolescents and youth in the planning*,* monitoring and evaluation of health services. We provide only healthcare services for adolescents and youth. We did not plan to include them in decision making.”* [35-years-old male, facility head]. *“If we (YC) do not involve adolescents and youth*,* the work cannot be effective. Meaningful participation is important. We involved adolescents and youth during program implementation and performance review. Since this YC was established for young people*,* we engage them in all aspects of the program. They even have their own committee.”* [36-years-old male, facility head]. The adolescents and youth heath program had not been evaluated at any of the HFs previously. However, all HFs conduct performance reviews biannually. In both HCs, the program performance review was conducted as part of integrated reviews with other health services. None of HCs had budget and/or plan for evaluation. “… *We (YC) conduct performance reviews of the AYH program twice a year using a checklist prepared by the Family Guidance Association of Ethiopia Bureau.*” [36 years old male, Facility head]. *“We have conducted the program performance review at the HC in integration with other programs. This was done twice a year by comparing our achievements with the respective plan. We have not evaluated AYH program. We did not plan evaluation due to lack budget for implementation”* *[34-years old-male, facility head].* Overall, 51.3% of the HCPs complied with the national AYHS guidelines during the provision of AYHSs, which was poor as per the judgment parameter (Table 4). Table 4Judgment on compliance dimension in the implementation evaluation of AYH program in Woliso town primary health facilities, Oromia, Ethiopia, 2023Indicators (9)EOWSAJPProportion of AY for whom at least one vital sign measured2034.00.615PoorProportion of AY for whom HIV/AIDS testing procedures was done as guideline in AYH clinic2014.50.25PoorProportion of abortion service given as guideline20204.54.5100Very goodProportion of female clients provided information about FP choices2054.51.125PoorProportion of AY client screened for malnutrition2003.00.00.0PoorProportion of AY client counseled on at least one NCD2003.00.00.0PoorProportion of STI cases treated as protocol15134.53.986.7Very goodProportion of history taken in privacy20204.04.0100Very goodProportion of AYHS reports sent to next HF timely within last 12 months12123.03.0100Very goodOverall compliance dimension3518.051.3PoorNote: *E* Expected (from each AYH clinic), *W* Weight, *O* Observed, *S* Score ((observed X weight)/Expected), *A* Achievement in percentage ((S/W) * 100), *JP* Judgment ParameterJP: >85% = very good, 75–84.9% = good, 60–74.9% = fair and < 60%= poor ### Satisfaction of adolescents and youth to adolescent and youth health services #### Sociodemographic characteristics of study participants A total of 411 adolescents and youth participated in the study, with a response rate of 97.4%. The majority (77.9%) of the participants were female. The mean age of the participants was 19.7 (SD ± 3.49) with more than half (57.7%) belonging to the 20–24 years age group. Nearly half (51.3%) of the sample individuals were married, and 156 (38.0%) were Protestant Christian followers. About half (51.1%) of them had completed education up to primary school, and 185 (45.0%) were currently students (Table 5). Table 5Sociodemographic characteristics of adolescents and youths in Woliso town primary health facilities, Oromia, Ethiopia, 2023 (*n* = 411)VariablesCategoriesFrequencyPercentSexFemale32077.9Male9122.1Age in completed years10–144210.215–1913232.120–2423757.7Marital statusSingle20048.7Married21151.3ReligionProtestant15638.0Orthodox13031.6Muslim10726.0Other^a^184.4Educational statusUnable to read and write20.5Primary school (1–8)21051.1Secondary school (9–12)12329.9Diploma and above7618.5OccupationStudent18545.0House wife7819.0Merchant4911.9Gov’t employed368.8Farmer348.3Other^b^297.0^a^Wakefata, Adventist (seventh day), and Catholic^b^No job, daily laborer #### Adolescents and youth satisfaction The finding showed that the overall percent mean satisfaction level of adolescents and youth was 75.7%. Higher percent mean satisfaction were observed for HCPs’ respection (86.6%), availability of essential drugs (80.4%), response to their questions (80.8%), and counselling services (78.0%). Furthermore, moderate percent mean satisfaction were reported for the comfortability of the waiting area (76.9%), waiting time (76.6%), and the direct financial cost of services (76.2%). On the other hand, lower percent mean satisfaction were recorded for special attention given to adolescents and youth (57.4%), service opening hours (68.5%), and privacy during service provision (75.3%) (See Table 6). *“I don’t think HCPs pay special attention to us (young people). We only receive detail counseling when we specifically asked for it. The service opening hour is also the same as those for older age groups. Since most of us are students*,* the government working hours could interfere with our education.”* *[19 years old male, service user].* *“In our HC*,* only one HCP is assigned to the AYH clinic. The imbalance between the number of HCPs and service users leads to extended waiting times. On market days*,* when more people come for shopping*,* medical treatment*,* or family planning services*,* waiting times can exceed one hour. As there is no separate waiting area for adolescents and youth*,* prolonged waiting may compromise their privacy and leads to poor satisfaction.”* *[35-years-old male, HCP].* Table 6Judgment matrix for satisfaction dimension on evaluation of AYH program at Woliso town primary health facilities, Oromia, Ethiopia, 2023Indicators (10)EOWSAJPPercent mean satisfaction of AY to counselling services100%78.33.52.778.3GoodPercent mean satisfaction of AY to direct financial cost of the services100%76.23.52.776.2GoodPercent mean satisfaction of AY to special attention for service users100%57.43.52.057.4PoorPercent mean satisfaction of AY to comfortability of waiting area100%76.93.52.776.9GoodPercent mean satisfaction of AY to privacy during service provision100%75.33.52.675.3GoodPercent mean satisfaction of AY to opening hour of the service100%68.53.52.468.5FairPercent mean satisfaction of AY to the waiting time to get service100%76.63.52.776.6GoodPercent mean satisfaction of AY to health care providers respect100%86.63.53.086.6Very goodPercent mean satisfaction of AY to answers given by providers for their question100%80.83.52.880.8GoodPercent mean satisfaction of AY to availability of drugs in health facility100%80.43.52.880.4GoodOverall satisfaction to AYHSs3526.075.7GoodNote: *E* Expected (from each AYH clinic), *W* Weight, *O* Observed, *S* Score ((observed X weight)/Expected), *A* Achievement in percentage ((S/W) * 100), *JP* Judgment ParameterJP: >85% = very good, 75–84.9% = good, 60–74.9% = fair and < 60%= poor #### Factors associated with adolescents and youth satisfaction As explained in the materials and method section, we have employed multivariable linear regression to identify factors associated with adolescents’ and youth's satisfaction with AYHSs. In the multivariable linear regression analysis, variables such as HF, service type, receiving all service demanded, and prior visits to HFs for AYHSs were significantly associated with satisfaction level. Accordingly, adolescents and youth received services at YC had a 0.084 higher satisfaction score compared to those received at HC N*o*1 AYH clinic (β = 0.084, 95% CI; 0.049, 0.119). Our result reveals that respondents who have ever visited HFs for AYHSs had a 0.031 higher satisfaction score than their counterparts (β = 0.031, 95% CI: 0.004, 0.058). The result further reveals that adolescents and youth who used the AYHSs free of charge had 0.060 higher satisfaction score than those who paid for the services (β = 0.060, 95% CI; 0.029, 0.090). Moreover, adolescents and youth who received all demanded services at one HF had 0.099 higher satisfaction score compared to those referred other HFs (β = 0.099, 95% CI; 0.065, 0.132) (Table 7). *“Medical costs are becoming very expensive. I am a student and not engaged in any income-generating activities. To access services*,* I have to pay. Even if the price is relatively low*,* it is still difficult to afford.”**[23 years old female, service user].* Table 7Predictors of level of satisfaction of adolescents and youth to AYHSs in the selected health facilities (*N* = 411)VariablesCategoriesFrequency *N*, (%)Unstandardized coefficientsBetaStandardized coefficientsBeta*P*-valueConfidence intervalLower, UpperHealth facility^a^HC N*o*.2111 (27.0)0.0080.0250.619−0.024, 0.041YC165 (40.2)0.0840.2790.000**0.049, 0.119Ever visit HFs for AYHSsYes217 (52.8)0.0310.1030.026*0.004, 0.058No194 (47.2)Payment for serviceFree157 (38.2)0.0600.1950.000**0.029, 0.090Paid for services254 (61.8)Receive all service demandedYes326 (79.3)0.0990.2690.000**0.065, 0.132No85 (20.7)^a^HC No.1 was used as a base category (comparison group); ** and * means statistically significant at less than 1 and 5 percent significance level, respectively ## Discussions The study evaluated the process of the AYH program implementation in Woliso Town, Oromia Region, Ethiopia. The overall process of the program implementation was found to be 69.6%, which is below the standards set by the National Adolescents and Youth Health Strategy (2021–2025) [4]. It is also lower than the WHO’s 75.0% cutoff point for service accessibility and acceptability criteria [25]. This lower performance might be attributed to the insufficiency of human resources and the inadequacy of service delivery rooms and waiting areas. However, the current finding is greater than values obtained in Sendafa Town (58.0%) [19], Northeast Ethiopia (50.8%) [26] and Southern Ethiopia (48.5%) [16]. This deference could be explained by differences in commitment of HCPs and management staff. The majority (81.8%) of the resources required for AYH program implementation were available, which is in line with the standards set by National Adolescent and Youth Health Strategy. In addition to this, the finding is also inconsistent with the WHO’s 75.0% cutoff point and exceeds the values obtained from studies conducted in West Gojjam (61.1%) [27] and Sendafa Town (76.6%) [19]. This might be due to difference in the commitment of HF managers and management staff and the presence of more donor support in the current study area. None of the HFs had separated entrance and exit gates, which might negatively affect the privacy and confidentiality of service users. This finding is lower than the result of a survey conducted in urban HFs of Rwanda, which showed 35.7% of HFs have a separate entrance for adolescents [28]. This may result from a shortage of budget and failure to plan for separation. The current finding also showed a shortage of HIV/AIDS test kits in YC, which may undermine early detection of HIV/AIDS and increase the risk of transmission among undiagnosed HIV-positive individuals. Moreover, there was a shortage of long-acting family planning drug (Implanon next) and medical abortion drugs (misoprostol and mifepristone) in both HCs within the past six months of study period. This finding is in agreement with the results of a study conducted in public HCs in Sendafa Town, which reported stock-outs of HIV test kits, contraceptives and misoprostol [19]. There was also a shortage of information, education, and communication (IEC) materials displayed in the waiting area of both HCs’ AYH clinics. This finding is in line with the study conducted in India at Ujala clinics [20]. Regarding the guidelines and protocols, all AYH clinics had almost all case management guidelines for minimum service delivery packages. This is consistent with the National Adolescent and Youth Health Strategy standards and with the results of study conducted in Harar Town, East Ethiopia [29]. However, the current finding is higher than the result of a global survey [30] which showed that less than half of the HFs had guidelines. None of AYH clinics has the current adolescent and youth health strategy (2021–2025), which is against AYHS standards. The possible explanation for this could be failure to distribute the strategy to HFs or AYH clinics by higher governing bodies (such as focal persons at the Town Health Office, Zonal Health Department) or a failure to download and print it. It could negatively affect service delivery quality and HCPs’ compliance. The evaluation findings showed that almost half (51.3%) of the AYHSs were implemented in line with the AYH national standards. This is much lower than the standards set by Ethiopia’s National Adolescent and Youth Health Strategy and implies poor quality of service. The finding is also lower than the WHO’s 75.0% cutoff point. This may be because of the limited availability of service delivery rooms (only one service delivery room in both HCs’ AYH clinics) and insufficient number of HCPs assigned to AYH clinics, especially at both HCs’ AYH clinics as well as a lack of adequate refresher training. However, the current finding is higher than the findings of studies conducted in Northeast Ethiopia (46.5%) [26] and Southern Ethiopia (42.0%) [16]. The possible explanation for discrepancies may be due to difference in the technical skills and competency of HCPs. The finding further reveals that only for one (5%) service user the HCP introduced himself which is important to build a good rapport. This finding is consistent with studies conducted in different parts of Ethiopia, where none of the HCPs introduced themselves to the client [16, 19, 26, 27]. Vital signs were measured for only three (15.0%) clients. This result is similar to the findings from a study conducted in Sendafa Town (12.5%) but lower than those reported in studies from Northeast Ethiopia (36.0%) and Southern Ethiopia (66.6%). This result might be due to negligence of service providers. Client- HCP interaction results showed that for all service users, history was taken in privacy (in a closed room and by speaking in a low voice close to the service users). This finding is supported by studies conducted in Arba Minch Town of southern Ethiopia and Dahana District of northeast Ethiopia, which showed auditory privacy was protected for all clients. However, none of the service users were assured about confidentiality, which may affect service-seeking among adolescents and youths. The result is similar with the result of study done at Sendafa Town but lower than the finding from Arba Minch Town, where confidentiality was assured for 33.3% of clients. Adolescents and youths did not participate in the planning, monitoring, and evaluation of AYHSs, or in decision-making regarding their own care and other appropriate aspects of service provision in both HCs. This is contrary to the existing AYH strategy and may negatively impact adolescents’ and youths’ health literacy. However, this finding is consistent with the result of study conducted in Northeast Ethiopia [26] and lower than the findings from a study conducted in Gojjam, Northwest Ethiopia, which showed that three (16.7%) HFs involved youth in the provision of AYHSs (information) in school and communities. The overall percent mean satisfaction of adolescents and youths with AYHSs in Woliso Town PHFs was 75.7%, which is consistent with the 75.0% cutoff point of the WHO [25]. However, the current finding is lower than those reported in studies conducted in Kuwait (99.6%) [31], Tanzania (89.0%) [32], South Africa (81.7%) [33], and Jimma University Medical Center (77.0%) [34]. A possible explanation for this could be the relatively higher number of HCPs, better diagnostic facilities, and superior service delivery quality in these HFs, as most are at the hospital level—except for the facility in Tanzania. In addition, differences in health service delivery systems for adolescents and youths between countries may account for the variation other than the later HF. On the other hand, the current finding is higher than those reported in studies in Iran’s Karman province (49.6%) [35], Serbia (42.8%) [36], West Amhara Region (39.3%) [37], Dasse (58.9%) [38], Dejen (60.7%) [39], and Sendafa Town (70.3%) [19]. The possible explanation for this could be due to difference in sociocultural characteristics, difference in commitment of HF managers and HCPs, and subjective nature of measuring satisfaction. Adolescents and youth who received services at YC had a 0.084 higher satisfaction score compared to those received at the HC N*o*1 AYH clinic. This might be because YC has a more comfortable waiting area that better protects confidentiality and privacy. In addition to this, there is also plenty of information, education and communication materials and donor support at YC. This study also revealed that respondents who had ever visited HFs for AYHSs had a 0.031 higher satisfaction score than their counterparts. This could be explained by the fact that clients with frequent or repeated visits and contact with HCPs are more likely to become aware of the presence of AYHSs and receive new information and knowledge regarding services. Such interactions might also create a sense of trust and friendship with the HCPs. This finding is supported by the result of studies conducted Sendafa Town [19] and western Ethiopia [40]. Participants who received the service free of charge had 0.060 higher satisfaction score than those who paid for the services. This may be attributed to the financial capacity to pay or high medical costs may not be affordable for young ages and value for money is higher in developing countries. This finding is in agreement with the results of another similar study conducted at Northeast Ethiopia [26], where participants who received services free of charge were more likely satisfied than those who paid. Moreover, respondents who received all services demanded at the HF had 0.099 higher satisfaction score compared to their counterparts. This may be attributed to the fact that someone’s expectation is fulfilled as they receive what they want, which is in line with WHO standards. Moreover, service users may feel their needs are unmet if they are transferred to other HFs, leading to lower satisfaction. This finding is also consistent with studies conducted in Dejen district [39] and Sendafa Town [19]. ### Limitations The hawthorn effect, which might have occurred during the direct observation of the interactions between service users and HCPs, could have overestimated the findings. To minimize this, the first three observations were dropped from the analysis. The role of chance, information bias, and social desirability bias is also likely, as clients were interviewed in the HFs compound which may have further contributed to overestimation. To reduce these biases, a detailed explanation of the evaluation’s purposes was given for key informants and study participants. Since the evaluation employed a case study design, it may not be possible to generalize to other PHFs unless they are in similar settings. In addition, the study is focused only on clients who visited HFs, limiting its generalizability to adolescents and youth who did not receive the services at HFs during the study period. ## Conclusion All HFs had the minimum required resources to provide AYHSs to adolescents and youths. Two trained HCPs were available at both HCs and YC, although only one HCP was assigned to AYH clinic at each HC. From essential drugs, spectinomycin and diazepam were not available. To make quality AYH service accessible to adolescents and youth, it is essential to assign additional trained HCPs to AYH clinics and ensure the availability of all required essential drugs. There was also shortage of IEC materials at both HCs’ AYH clinics. Integrated AYH registration was available at YC only, and none of AYH clinic had the Adolescent and Youth Health Service Strategy (2021–2025) at the time of assessment. Standardized registration and adequate IEC material are necessary to capture quality data which helps to improve service quality. For most of service users, vital sign measurement, HIV/AIDS tests, nutritional screening, and counseling on family planning choices and non-communicable diseases were not conducted as per protocol. This requires HCPs to adhere to AYH standards and guidelines. Furthermore, zonal health department and district health office managers have to facilitate or conduct constructive regular supportive supervision. Service users are participated in planning, program implementation, and performance review at YC only. Therefore, HCs have to improve adolescents' and youth’s engagement and use their feedback into quality improvement cycle. While the overall satisfaction of adolescents and youth with AYHSs was good, satisfaction remain moderate in areas such as privacy, service availability, and special attention for adolescents—areas that require increased focus from HF managers. Receiving services at YC, having ever received AYHSs, use of the service free of charge, and receiving all demanded service at one HF were associated with a high satisfaction score. ## Supplementary Information Additional file 1. Logic model to evaluate AYHSs in Woliso Town PHF, Oromia, Ethiopia, 2023 Additional file 2. Stakeholder identification and analysis matrix, at Woliso Town PHFs, Oromia, Ethiopia, 2023 Additional file 3. Indicator relevance matrix of the evaluation of AYHSs at Woliso Town PHFs, Oromia, Ethiopia, 2023