Adolescent Health Services in Primary Health Care and Providers’ Perspectives on Access, Quality, and Utilisation Gaps

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This study assessed the availability, delivery, and perceived quality of adolescent SRH services in Albanian primary healthcare centers, barriers faced by healthcare personnel and the role of NGOs. A cross-sectional study was conducted among 399 healthcare professionals across three districts of Albania (Elbasan, Shkoder, and Durres). Data were collected on service provision, staff training, resource availability, and perceived quality of adolescent SRH services. Associations between training, service coverage, geographic location, and proposed improvement strategies were analyzed using chi-square tests. Service delivery varied significantly between rural and urban settings (p < 0.001). Staff training was strongly associated with broader SRH service coverage (p < 0.001). Key barriers to service provision included inadequate training, limited resources, and institutional constraints. Nurses were identified as the primary service providers. However, SRH services rarely targeted high-risk or marginalized adolescent populations. Perceived service quality was significantly associated with proposed improvement strategies (p = 0.002). Only 19.3% of respondents reported the presence of NGO-led adolescent sexual and reproductive health (SRH) projects in their facilities, whereas 50% indicated no NGO involvement. Support from non-governmental organizations (NGOs) to primary health centers (PHCs) was limited, with only 15.5% reporting such assistance. Adolescent SRH services in Albania remain fragmented and uneven. Strengthening staff training, enhancing coordination with NGOs, and developing targeted approaches for high-risk adolescent groups are essential to improve access, quality, and equity of adolescent SRH services. Adolescent health Primary care SRH NGO collaboration training 1. Introduction Adolescence represents a critical window for sexual and reproductive health (SRH) interventions, as young people face elevated risks of sexually transmitted infections (STIs), unintended pregnancy, sexual violence, and mental health vulnerabilities [ 3 ]. Primary healthcare (PHC) services play a pivotal role in addressing these needs through prevention, counseling, early diagnosis, and referral pathways. Despite global recognition of adolescent SRH as a public health priority, substantial gaps persist in the availability, accessibility, and quality of adolescent-responsive services within primary care settings [ 4 ]. Recent international evidence indicates that adolescents frequently encounter structural and interpersonal barriers when seeking care, including lack of privacy, limited confidentiality safeguards, judgmental provider attitudes, and inadequate youth engagement strategies [ 5 , 6 ]. These challenges are more pronounced in low- and middle-income countries, where systemic constraints such as insufficient infrastructure, shortages of trained personnel, fragmented service organization, and weak referral mechanisms undermine the implementation of youth-friendly standards [ 7 ]. Healthcare providers’ competencies, attitudes, and institutional support systems play a critical role in shaping adolescents’ healthcare utilization. Evidence from the past decade indicates that provider training in adolescent-centered communication, confidentiality, and non-discriminatory practices is positively associated with increased service uptake and improved perceived quality of care among adolescents [ 8 – 10 ]. In contrast, inadequate training and weak institutional frameworks may reinforce stigma and act as barriers to access, particularly for adolescents from vulnerable or marginalized populations [ 9 , 10 ]. In Albania, adolescent SRH has gained increasing policy attention in recent years. The National Action Plan for Sexual and Reproductive Health 2022–2030 prioritizes the expansion of adolescent-friendly services, enhancement of confidentiality standards, reduction of stigma, and strengthening of intersectoral collaboration, especially in rural and underserved areas [ 11 ]. However, empirical evidence assessing the implementation of these strategic objectives at the primary healthcare level remains limited. Existing national studies have primarily focused on general SRH indicators and population-level outcomes, offering limited insight into service organization, provider perspectives, training coverage, and the practical integration of adolescent-friendly approaches in PHCs. Furthermore, the contribution of non-governmental organizations (NGOs) in complementing public primary healthcare (PHC) services through capacity building, community outreach, awareness campaigns, and targeted interventions for high-risk adolescent populations has not been systematically examined in the Albanian context. International evidence indicates that structured NGO engagement can expand service coverage, strengthen provider competencies, and improve access for marginalized adolescents when effectively integrated within public health systems [ 12 – 14 ]. However, fragmented coordination mechanisms and limited institutional integration may undermine the sustainability and long-term impact of such initiatives. Given these knowledge gaps, this study aims to assess the provision of adolescent health services in primary healthcare centers in Albania. Specifically, it examines: (1) the availability and delivery of adolescent-friendly services; (2) healthcare providers’ perceptions of service quality; (3) barriers related to training, institutional support, and resource availability; and (4) the role of NGO involvement in strengthening adolescent SRH services across urban and rural settings. By providing empirical evidence from frontline healthcare staff, this study seeks to inform policy implementation and support the development of more equitable, coordinated, and youth-responsive primary healthcare services. 2. Materials and Methods 2.1 Study Design A cross-sectional survey design was employed to assess the availability, delivery, and perceived quality of adolescent sexual and reproductive health (SRH) services in primary healthcare centers (PHCs) in Albania. The study also examined the role of non-governmental organizations (NGOs) and identified barriers encountered by healthcare staff. Cross-sectional methodology allowed for the collection of quantitative data from multiple districts simultaneously to provide a comprehensive overview of service provision and staff perceptions. 2.2 Study Setting and Population The study was conducted in three Albanian districts: Elbasan, Shkoder, and Durres. These districts were selected to represent both urban and rural primary healthcare settings, capturing variability in service delivery models, access, and population characteristics. The target population included healthcare staff working in PHCs, including physicians, nurses, midwives, and administrative staff involved in adolescent health service provision. 2.3 Sampling Strategy and Sample Size A stratified random sampling approach was employed to recruit participants across the three districts. Each primary healthcare center (PHC) was considered a stratum to ensure proportional representation of both urban and rural facilities. A total of 399 healthcare providers participated in the study. The sample size was calculated to ensure adequate statistical power to detect significant associations between staff training, service delivery characteristics, and perceived service quality, assuming a 95% confidence level and a 5% margin of error. 2.4 Inclusion and Exclusion Criteria Inclusion criteria : Healthcare staff employed at PHCs in the selected districts. Staff involved directly or indirectly in the provision of adolescent health services. Willingness to participate and provide informed consent. Exclusion criteria : Staff on temporary leave or absent during the data collection period. Personnel not involved in adolescent health service provision. 2.5 Data Collection Instrument and Procedure Data were collected using a structured, self-administered questionnaire developed based on WHO guidelines for adolescent-friendly health services and existing literature on adolescent SRH in primary care [ 1 – 4 ]. The instrument included sections on: Socio-demographic characteristics and professional experience. Service delivery models by facility type and area (Table 1 ). Staff training and provider distribution (Tables 2 – 3 ). Targeted adolescent populations (Table 4 ). Perceived service quality and suggested improvements (Tables 5 – 6 ). Barriers to service provision (Table 7 ). Presence of NGO-led adolescent SRH projects (Tables 8 – 9 ). Questionnaires were administered in person by trained research assistants. Participants completed the questionnaires anonymously during working hours. Clarifications were provided when necessary to minimize potential misunderstandings and ensure consistency in responses. 2.6 Reliability and Validity The questionnaire was pre-tested among a small sample of PHC staff (n = 20) outside the study districts to assess clarity, relevance, and comprehension. Internal consistency of Likert-scale items (e.g., perceived service quality) was evaluated using Cronbach’s alpha, with a threshold of ≥ 0.7 considered acceptable. Content validity was ensured through expert review by public health specialists and adolescent SRH experts. 2.7 Ethical Considerations The study protocol was reviewed and approved by the Ethics Committee of the University of Elbasan “Aleksander Xhuvani” (Protocol No. 880), which served as the coordinating institution for the project. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and strict confidentiality was maintained throughout the study. All data were anonymized prior to analysis and stored securely in accordance with institutional data protection policies. 2.8 Statistical Analysis Descriptive statistics were computed to summarize frequencies, percentages, and cumulative distributions of responses across all variables. Associations between categorical variables, such as staff training and service provision, urban/rural location, and perceived service quality, were examined using chi-square tests. Statistical significance was defined as p < 0.05. Analyses were conducted using SPSS version 26.0. 2.9 Data Management and Quality Assurance Completed questionnaires were checked for completeness and consistency before data entry. Double-entry procedures were applied to minimize data entry errors. Missing or ambiguous responses were cross-verified with field notes where possible. Ongoing supervision by the research team was implemented to maintain consistency and ensure compliance with standardized data collection procedures across all districts. 2.10 Clinical Trial Registration This study was observational and did not involve clinical interventions; therefore, it was not registered as a clinical trial. The study adhered to the STROBE guidelines for observational studies to ensure methodological rigor and transparency in reporting. 3. Results 3.1. Distribution of adolescent health service delivery by area (urban and rural) Table 1 presents the distribution of adolescent health service delivery models according to geographic area (urban vs rural). In rural areas, adolescent health services were more frequently delivered through village clinics (n = 100) and health centers (n = 129), with limited provision at neighborhood clinics (n = 12). In contrast, in urban areas, services were predominantly concentrated at health centers (n = 138), while only a small number were delivered at village clinics (n = 7) or neighborhood clinics (n = 13). The association between geographic area and service delivery point was statistically significant (χ² = 66.800, p < 0.001), indicating a clear structural difference in how adolescent services are organized across rural and urban settings. These findings suggest that rural service provision relies more heavily on decentralized village clinics in addition to health centers, reflecting the need to ensure geographic accessibility in areas with dispersed populations. Conversely, urban areas appear to centralize adolescent service delivery primarily within health centers, potentially benefiting from greater infrastructure concentration but possibly limiting accessibility for adolescents who face transportation, social, or confidentiality barriers. The statistically significant disparity highlights structural inequalities in service organization between rural and urban settings. While rural decentralization may improve physical access, it may also raise concerns regarding staffing capacity, availability of trained staff, and confidentiality in smaller community-based facilities. In urban areas, service centralization may enhance resource concentration but could inadvertently reduce outreach to vulnerable or marginalized adolescents who may not routinely access formal health centers. Overall, these results underscore the importance of geographically tailored strategies to ensure equitable access to adolescent-friendly health services, with attention to both structural accessibility and quality-of-care standards across different service delivery points. Table 1 Distribution of adolescent health service delivery by area (urban and rural) Is this service provided P-value At the village clinic At the neighborhood clinic Only at the Health Center Area Rural Area 100 12 129 .000 χ² = 66.800 Urban Area 7 13 138 Total 107 25 267 3.2. Number of trained staff and distribution of providers delivering adolescent sexual and reproductive health services in PHCs Table 2 presents the association between the number of trained staff in adolescent sexual and reproductive health (SRH) and the number of providers delivering these services within primary healthcare centers (PHCs). A statistically significant association was observed between staff training and service delivery capacity (χ² = 270.337, p < 0.001). PHCs with only one trained staff member most commonly reported that adolescent SRH services were provided by a single provider (n = 52), with limited multi-provider involvement. Similarly, centers with two trained staff members primarily reported service provision by two providers (n = 40). In contrast, PHCs with several trained staff were substantially more likely to report that adolescent SRH services were delivered by several providers (n = 72), indicating broader internal service coverage and potentially greater continuity of care. Centers without trained staff most frequently reported the absence of adolescent SRH services (n = 69). Nevertheless, a proportion of facilities lacking formally trained staff indicated that limited services were provided by one or more healthcare providers. This finding suggests that adolescent SRH services may, in some instances, be delivered in the absence of specialized adolescent-focused training. These findings demonstrate a strong and direct relationship between training coverage and the scope of adolescent SRH service delivery. Facilities with a higher number of trained professionals appear better positioned to distribute service responsibilities among multiple providers, which may enhance accessibility, reduce service interruptions, and improve quality of care. Conversely, the absence of trained personnel is strongly associated with service non-provision, underscoring training as a critical determinant of service availability. From a health systems perspective, the magnitude of the association (χ² = 270.337) highlights staff capacity-building as a central structural factor influencing adolescent SRH service implementation in PHCs. Expanding training programs and ensuring equitable distribution of trained personnel across facilities may therefore represent a key strategy for strengthening adolescent-friendly service coverage and improving overall system responsiveness. Table 2 Number of trained staff and distribution of providers delivering adolescent sexual and reproductive health services in Primary Health Care Centers (PHCs) By how many people is this service provided? P-value One provider Two providers Several providers None Trained staff for adolescent sexual and reproductive health services One provider 52 12 7 6 .000 χ² =270.337 Two providers 4 40 9 3 Several providers 30 21 72 6 None 27 10 31 69 3.3. Years of experience of primary healthcare staff Table 3 presents the distribution of respondents according to their years of experience in primary healthcare. The largest proportion of participants reported 1–5 years of professional experience (24.1%, n = 96), followed by those with more than 20 years of experience (22.3%, n = 89). Staff with 6–10 years of experience accounted for 18.8% (n = 75), while 17.3% (n = 69) had 11–15 years of service. Smaller proportions were observed among participants with less than 1 year of experience (10.0%, n = 40) and those with 16–20 years of experience (7.5%, n = 30). The distribution indicates a relatively balanced workforce composition, combining early-career professionals with highly experienced personnel. Notably, nearly one quarter of respondents have more than two decades of experience, suggesting substantial institutional memory and long-standing engagement in primary care service delivery. At the same time, approximately one third of the sample (34.1%) consists of staff with five or fewer years of experience, reflecting generational renewal within the workforce. From a health systems perspective, this heterogeneous experience profile has important implications for adolescent health service delivery. Early-career professionals may be more recently exposed to updated curricula and contemporary adolescent health frameworks, while highly experienced staff may rely more on accumulated clinical practice. However, as shown in previous analyses (Section 3.2), perceived training gaps were reported across all experience categories, indicating that both new and senior personnel may require continuous professional development in adolescent-specific competencies. Overall, the experience distribution suggests that capacity-building strategies should be inclusive and tailored to different professional stages. Continuous in-service training, mentorship models combining senior and junior staff, and standardized adolescent-friendly service guidelines may help ensure consistent quality of care across diverse levels of professional experience. Table 3 Years of experience of primary healthcare staff Frequency Percent Valid Percent Cumulative Percent Valid > 1 year 40 10.0 10.0 10.0 1–5 years 96 24.1 24.1 34.1 6–10 years 75 18.8 18.8 52.9 11–15 years 69 17.3 17.3 70.2 16–20 years 30 7.5 7.5 77.7 Over 20 years 89 22.3 22.3 100.0 Total 399 100.0 100.0 3.4. Target adolescent groups for health service provision by districts Table 4 shows the distribution of primary healthcare staff responses regarding the adolescent groups targeted by health services across the districts of Elbasan, Shkoder, and Durres. The majority of respondents (74.2%, n = 296) reported that services are provided to adolescents in general, without specific targeting of high-risk or marginalized populations. A smaller proportion of staff indicated that services were directed at multiple groups, either selecting more than one option (17.0%, n = 68) or all of the above (5.0%, n = 20). Targeted service provision for high-risk or marginalized adolescent groups was notably limited. Only 2.5% of respondents reported delivering services specifically to adolescents engaging in high-risk behaviors (n = 10), while 0.2% reported targeting adolescents from ethnic minority communities (n = 1) and 0.2% those from socioeconomically disadvantaged families (n = 1). This distribution was consistent across all three districts, with only minor variations in absolute numbers. These findings indicate that adolescent health services within Albanian PHCs are predominantly generalized in scope and may insufficiently address the distinct needs of vulnerable or high-risk populations. The limited implementation of targeted interventions suggests a potential gap in service equity and inclusiveness, which may contribute to persistent disparities in sexual and reproductive health outcomes. These results highlight the importance of designing and integrating targeted, equity-oriented strategies within primary healthcare services to better reach adolescents at heightened risk, including those engaging in high-risk behaviors, from marginalized ethnic communities, or experiencing socioeconomic disadvantage. Strengthening outreach programs, tailoring service delivery to specific populations, and integrating social determinants of health into adolescent care planning could enhance service equity, accessibility, and effectiveness across different districts. Overall, the findings underscore the importance of complementing generalized adolescent health services with targeted interventions to ensure that high-risk and marginalized groups are not overlooked in primary healthcare provision. Table 4 Target adolescent groups for health service provision by districts District Total Elbasan Shkoder Durres Which group (or groups) of adolescents do you aim to provide health services to? Young people with risky behaviors 2(0.5%) 5(1.2%) 3(0.7%) 10(2.5%) Young people from ethnic communities - 1(0.2%) -- 1(0.2%) Young people from socioeconomically disadvantaged families 1(0.2%) - - 1(0.2%) Young people in general 140(35.1%) 77(19.3%) 79(19.8%) 296(74.2%) All of the above 6(1.5%) 4(1.0%) 10(2.5%) 20(5.0%) More than one option 23(5.7%) 21(5.3%) 24(6.0%) 68(17.0%) 3.5. Assessment of adolescent health service quality by districts Table 5 presents healthcare staff’s assessment of the quality of adolescent health services across three Albanian districts: Elbasan, Shkoder, and Durres. Overall, the majority of respondents rated service quality as good (26.7%, n = 107) or very good (36.3%, n = 145), indicating a generally positive perception of adolescent health service delivery. Services were rated as average by 21.8% of participants (n = 87), while only a minority of respondents assessed services as poor (7.7%, n = 31) or very poor (7.2%, n = 29). District-level comparisons reveal variability in perceived service quality. Elbasan had the highest proportion of respondents rating services as very good (17.3%, n = 69), while Shkodra had a lower proportion in this category (8.5%, n = 34). Durres showed a relatively balanced distribution across good (9.5%, n = 38) and very good (10.5%, n = 42) ratings. Similarly, Elbasan reported slightly higher frequencies of average ratings (9.8%, n = 39) compared to the other districts. The observed differences may reflect variations in resource allocation, staff capacity, training coverage, infrastructure, or the presence of NGO-supported initiatives across districts. For instance, districts with higher concentrations of trained staff or better coordination with NGOs may contribute to elevated perceptions of service quality. Conversely, districts with fewer trained staff or limited facility infrastructure may experience lower perceived service performance. These findings highlight that, while overall perceptions are positive, district-level disparities persist, suggesting the need for targeted interventions to ensure equitable quality of adolescent health services across different geographic regions. Policy strategies could include harmonizing staff training programs, standardizing adolescent-friendly service protocols, and facilitating inter-district sharing of best practices to reduce quality variation. In conclusion, the results emphasize both overall satisfaction with service provision and the importance of addressing local disparities to achieve consistent, high-quality, and youth-responsive primary healthcare for adolescents across Albania. Table 5 Assessment of adolescent health service quality by districts District Total Elbasan Shkoder Durres Assessment of the quality of services provided for adolescents Very poor 15(3.7%) 8(2.0%) 6(1.5%) 29(7.2%) Poor 15(3.7%) 7(1.8%) 9(2.2%) 31(7.7%) Average 39(9.8%) 26(6.5%) 22(5.5%) 87(21.8%) Good 34(8.5%) 35(8.7%) 38(9.5%) 107(26.7%) Very good 69(17.3%) 34(8.5%) 42(10.5%) 145(36.3%) 3.6. Assessment of adolescent health service quality and suggestions for improvement in primary healthcare centers Table 6 presents the association between healthcare staff’s assessment of the quality of adolescent health services and their proposed strategies for service improvement. A statistically significant association was identified between perceived service quality and suggested improvement measures (χ² = 54.309, p = 0.002), indicating that staff perceptions of quality meaningfully influenced their proposed priorities for strengthening services. Among respondents who rated services as very poor or poor, improvement strategies were more frequently focused on staff training, promotion of health education, and selecting more than one option, reflecting recognition of multiple systemic weaknesses. In particular, staff who perceived services as very poor most commonly emphasized training (2.0%) and multiple combined interventions (2.5%). Participants who rated services as average most frequently prioritized staff training (3.7%) and the selection of multiple improvement strategies (11.3%). This pattern suggests that even when service performance is perceived as moderate, respondents recognize the need for comprehensive and multifaceted strengthening efforts. Among those who rated services as good or very good, responses were more diverse. Staff in these categories frequently selected promotion of health education, creating a suitable environment, and ensuring privacy and confidentiality. Notably, respondents who rated services as very good still identified multiple areas for improvement, particularly health education promotion (7.5%) and combined strategies (13.8%), indicating ongoing awareness of optimization needs even within relatively well-performing centers. Across all quality categories, selecting “ more than one option ” and “ all of the above ” was common, reinforcing the perception that improving adolescent health services requires comprehensive interventions rather than isolated measures. Although options such as use of technology and social media and adapting service hours were selected less frequently, their presence indicates growing recognition of innovative and youth-centered approaches. From a health systems perspective, the observed association between perceived service quality and proposed improvement strategies underscores the value of incorporating frontline provider perspectives into service planning and quality improvement processes. Providers who perceived lower service quality were more likely to prioritize structural capacity-building measures, particularly staff training. In contrast, those reporting higher perceived quality tended to emphasize enhancements related to the service environment and confidentiality practices. Overall, the findings suggest that strengthening adolescent health services in primary healthcare centers requires integrated strategies that combine workforce training, infrastructure improvements, confidentiality safeguards, community health education, and modernization of service delivery approaches. The statistically significant relationship between quality perception and proposed interventions underscores the need to incorporate healthcare provider feedback into adolescent health policy and program development. Table 6 Assessment of adolescent health service quality and suggestions for improvement in primary health care centers How could adolescent services be improved at your health center? P-value Promotion of health education Creating a suitable environment for this service Training of staff to provide this service Ensuring privacy and confidentiality Use of technology and social media Adapting service hours All of the above More than one option How would you rate the quality of the services you provide for adolescents? Very poor 6(1.5%) - 8(2.0%) 2(0.5%) 1(0.2%) - 2(0.5%) 10(2.5%) .002 χ² =54.309 Poor 3(0.7%) 2(0.5%) 5(1.3%) - - 1(0.2%) 8(2.0%) 12(3.0%) Average 9(2.3%) 2(0.5%) 15(3.7%) 4(1.0%) - 1(0.2%) 11(2.7%) 45 ( 11.3%) Good 19(4.18%) 11(2.7%) 6(1.5%) 2(0.5%) 4(1.0%) 1(0.2%) 14(3.5%) 50(12.5%) Very good 30(7.5%) 14(3.5%) 18(4.5%) 11(2.7%) 9(2.3%) 1(0.2%) 7(1.8%) 55(13.8%) 3.7. Barriers to providing adolescent health services according to years of primary care staff experience Table 7 presents the distribution of perceived barriers to adolescent health service provision according to years of experience in primary care. Overall, the most frequently reported barrier was lack of training and specific skills for adolescents (32.8%, n = 131). This concern was reported across all experience categories, with relatively higher frequencies among staff with 1–5 years (7.5%) and over 20 years of experience (7.3%). These findings suggest that insufficient adolescent-specific competencies are perceived as a systemic issue, affecting both early-career and highly experienced professionals. The second most commonly reported category was “ Other ” barriers (32.6%, n = 130), followed by selecting more than one option (16.0%, n = 64), indicating that many respondents perceive barriers as multifactorial rather than isolated. Lack of resources and infrastructure was identified by 13.0% (n = 52) of participants and was reported consistently across experience groups, though slightly more frequently among those with over 20 years of service (3.5%). In contrast, lack of communication ethics (1.8%, n = 7) and the cultural norms and values of healthcare personnel (1.5%, n = 6) were less frequently identified as primary barriers. This pattern may suggest that respondents perceive structural and capacity-related constraints as more significant impediments to service provision than interpersonal or attitudinal factors. Notably, both early-career professionals (≤ 1 year and 1–5 years of experience) and those with more than 20 years of service reported training deficits at comparable levels. This finding suggests that gaps in adolescent-specific competencies may not be sufficiently addressed through either pre-service education or continuing professional development. Mid-career staff (6–15 years of experience) also frequently identified resource limitations and skills-related barriers, further indicating that systemic constraints persist across different stages of professional practice. From a health systems perspective, these findings underscore that workforce capacity-building remains a central challenge in strengthening adolescent health services in primary care. While infrastructure and resource limitations are notable, the predominance of training-related barriers highlights the need for structured, continuous, and adolescent-focused professional development programs. Additionally, the high proportion of respondents identifying multiple barriers suggests that effective improvement strategies should adopt a comprehensive approach addressing training, institutional support, and structural resource allocation simultaneously. Overall, the results demonstrate that perceived barriers are widespread across all experience levels, indicating that strengthening adolescent health services requires system-wide interventions rather than targeted measures for specific staff cohorts. Table 7 Barriers to providing adolescent health services according to years of primary care staff experience Years of work in primary care Total > 1 year 1–5 years 6–10 years 11–15 years 16–20 years Over 20 years In your opinion, what are the barriers to providing health services for adolescents from the perspective of healthcare personnel? Lack of training and specific skills for adolescents 11(2.7%) 30(7.5%) 22 (5.5%) 25(6.3%) 14(3.5%) 29(7.3%) 131(32.8%) Lack of communication ethics 1(0.2%) 2(0.5%) 1(0.3%) 1(0.2%) - 2(0.5%) 7(1.8%) Cultures and values of healthcare personnel - - 1(0.3%) 2(0.5%) 1(0.2%) 2(0.5%) 6(1.5%) Lack of resources and infrastructure 8(2.0%) 10(2.5%) 11(2.7%) 6(1.5%) 3(0.7%) 14(3.5%) 52(13.0%) Other 13(3.3%) 35(8.8%) 30(7.5%) 21(5.3%) 7(1.8%) 24(6.0%) 130(32.6%) All of the above - 2(0.5%) 1(0.2%) 3(0.7%) 3(0.7%) - 9(2.3%) More than one option 7(1.8%) 17(4.3%) 9(2.3%) 11(2.7%) 2(0.5%) 18(4.5%) 64(16.0%) 3.8. NGO support in the provision of adolescent health services in primary healthcare centers Table 8 summarizes respondents’ perceptions regarding direct NGO support for adolescent health service provision within primary healthcare centers (PHCs). Only 15.5% (n = 62) of participants reported receiving NGO support in delivering adolescent health services. In contrast, more than half of respondents (54.1%, n = 216) indicated that their centers did not receive any NGO assistance. Additionally, 30.3% (n = 121) stated that they were unaware of whether such support was provided. These findings suggest that NGO involvement in the direct strengthening of adolescent health services at the PHC level is limited. Compared with the presence of NGO-led educational projects (Section 3.1 ), reported institutional support for service delivery appears even lower, indicating that NGO engagement may be more focused on community-based awareness activities rather than structural or capacity-building interventions within healthcare facilities. The high proportion of “ I don’t know ” responses again points to potential communication gaps, insufficient coordination mechanisms, or limited integration of externally supported initiatives into routine PHC operations. Lack of awareness among staff may also reflect the absence of formal collaboration agreements, unclear roles and responsibilities, or minimal institutional visibility of NGO contributions. From a health systems perspective, limited NGO support at the facility level may constrain opportunities for staff training, resource supplementation, outreach to vulnerable adolescent groups, and implementation of youth-friendly service standards. Strengthening formal partnerships between public primary care services and civil society organizations could enhance service coverage, improve quality of care, and support more targeted interventions for high-risk and marginalized adolescents. Overall, the findings reinforce the need for structured intersectoral collaboration frameworks to ensure that NGO engagement effectively complements and strengthens primary healthcare delivery for adolescents. Table 8 NGO support in the provision of adolescent health services in primary health care centers Frequency Percent Valid Percent Cumulative Percent Valid Yes 62 15.5 15.5 15.5 No 216 54.1 54.1 69.7 I don’t know 121 30.3 30.3 100.0 Total 399 100.0 100.0 3.9. Participation in NGO-led projects for adolescent sexual and reproductive health education Table 9 presents the distribution of responses regarding the presence of non-governmental organization (NGO)-led projects focused on adolescent sexual and reproductive health (SRH) information and education in the respondents’ service areas. Only 19.3% (n = 77) of primary healthcare staff reported the presence of NGO-supported adolescent SRH initiatives in their area. In contrast, nearly half of respondents (49.9%, n = 199) indicated that no such projects were being implemented. Additionally, 30.8% (n = 123) reported being unaware of whether NGO-led activities existed locally. These findings indicate limited integration and/or visibility of NGO-led adolescent SRH education initiatives within primary healthcare catchment areas. The relatively low proportion of confirmed NGO participation suggests that civil society engagement in adolescent SRH may be geographically restricted, project-based, or inconsistently coordinated with public sector services. Importantly, the high percentage of respondents who were unaware of NGO activities points to potential gaps in communication and institutional collaboration between NGOs and primary healthcare centers (PHCs). Such gaps may hinder effective referral mechanisms, reduce opportunities for joint outreach activities, and limit the continuity of adolescent-focused preventive and educational interventions. Overall, the results highlight fragmentation between public primary healthcare services and external stakeholders involved in adolescent SRH education. Strengthening structured collaboration frameworks, improving information-sharing mechanisms, and enhancing staff awareness of community-based initiatives may contribute to more coordinated, comprehensive, and youth-responsive service delivery. Table 9 Participation of NGOs in projects for adolescent sexual and reproductive health information and education in the area Frequency Percent Valid Percent Cumulative Percent Valid Yes 77 19.3 19.3 19.3 No 199 49.9 49.9 69.2 I don’t know 123 30.8 30.8 100.0 Total 399 100.0 100.0 4. Discussion Geographical disparities in service delivery models were also evident, with rural areas relying more heavily on village clinics and urban services concentrated in health centers. Similar rural-urban discrepancies have been reported in other middle-income countries, where decentralization improves physical accessibility but may compromise confidentiality, staffing capacity, and resource availability [ 15 ]. Ensuring equitable adolescent-friendly services requires context-adapted strategies that balance accessibility with quality standards, including privacy safeguards and adequately trained personnel [ 16 ]. Workforce training emerged as one of the most significant determinants of service provision. The strong statistical association between the number of trained staff and the availability of adolescent SRH services confirms that provider capacity is central to effective implementation. Recent evidence consistently demonstrates that healthcare providers trained in adolescent-friendly communication, confidentiality, and non-judgmental care are more likely to deliver comprehensive services and improve adolescents’ willingness to seek care [ 17 ]. Conversely, inadequate training remains one of the most frequently cited barriers in low- and middle-income countries, contributing to reduced service uptake and suboptimal quality of care [ 18 ]. The barriers identified by participants, including insufficient training, limited resources, and infrastructural constraints, are consistent with findings from comparable health systems, where structural weaknesses impede the effective delivery of adolescent services [ 19 ]. Although interpersonal barriers, such as provider attitudes, were less frequently reported in the present study, international evidence indicates that these factors may nonetheless shape adolescents’ care-seeking experiences, particularly in sensitive domains such as sexual and reproductive health [ 20 ]. The consistent reporting of training gaps across all levels of professional experience further suggests that both pre-service education and continuing professional development programs require strengthening. Perceived service quality significantly influenced proposed improvement strategies. Staff who rated services as poor prioritized training and educational promotion, whereas those who perceived higher quality emphasized environmental enhancements, privacy, and confidentiality measures. This reflects the multidimensional nature of quality in adolescent healthcare, encompassing technical competence, communication skills, confidentiality, and youth-centered service environments [ 21 ]. Adolescents consistently identify respectful communication, privacy, and trust as decisive factors in service utilization, reinforcing the importance of maintaining confidentiality standards within PHCs [ 22 ]. A particularly important finding concerns the limited targeting of high-risk or marginalized adolescent groups. Most services were reported to address adolescents in general, with minimal focus on young people with risky behaviors, those from low-income families, or ethnic minority communities. International literature highlights that universal service models, while essential, may fail to address disparities unless complemented by targeted outreach strategies for vulnerable populations [ 23 ]. Adolescents facing socioeconomic disadvantage or engaging in risk behaviors often encounter additional barriers to accessing SRH services, necessitating proactive, equity-oriented interventions [ 24 ]. Overall, the findings underscore the need for comprehensive system-level strengthening of adolescent SRH services in Albania. International experience indicates that sustainable improvements require integrated strategies combining workforce training, infrastructure investment, standardized youth-friendly service protocols, and formalized NGO-government collaboration mechanisms [ 25 ]. Strengthening monitoring frameworks and embedding adolescent-responsive indicators within primary care performance evaluation systems may further enhance accountability and equity. This study provides comprehensive evidence on the status of adolescent sexual and reproductive health (SRH) services within primary healthcare centers (PHCs) in Albania, highlighting structural, workforce, and coordination-related challenges. The findings demonstrate that adolescent services remain unevenly implemented, insufficiently coordinated with non-governmental organizations (NGOs), and limited in targeted outreach to vulnerable groups. These results are consistent with international evidence indicating that, despite global prioritization of adolescent SRH, implementation gaps persist at the primary healthcare level [ 26 ]. The limited reported engagement of NGOs in both educational initiatives and direct PHC support suggests weak intersectoral coordination. Although NGOs often play a complementary role in strengthening adolescent SRH services through outreach, awareness campaigns, and provider capacity building, their impact depends heavily on structured collaboration with public health systems [ 27 ]. Fragmented partnerships and a lack of institutional integration can reduce sustainability and limit service continuity, particularly in decentralized primary care contexts [ 28 ]. The high proportion of respondents unaware of NGO activities further underscores potential communication and coordination deficiencies within the system. 5. Conclusions This study highlights important structural and organizational gaps in the provision of adolescent sexual and reproductive health (SRH) services within primary healthcare centers (PHCs) in Albania. Although a considerable proportion of healthcare staff rated service quality as good or very good, the findings reveal significant inconsistencies in service availability, geographic distribution, workforce preparedness, and intersectoral collaboration. The limited presence and visibility of NGO-supported initiatives, combined with weak coordination between civil society and public primary care services, indicate missed opportunities for strengthening adolescent-focused outreach and capacity building. Furthermore, the strong association between staff training and service provision underscores the central role of workforce development in ensuring comprehensive and sustainable adolescent SRH services. Facilities with trained personnel were significantly more likely to provide services, while those without trained staff frequently reported service gaps. Geographic disparities between rural and urban service delivery models suggest the need for context-specific strategies to ensure equitable access. While rural decentralization may enhance physical accessibility, it requires adequate staffing, confidentiality safeguards, and resource allocation to maintain service quality. Urban centralization, although potentially resource-efficient, should be complemented by youth-friendly adaptations to reduce social and structural barriers. Importantly, services were predominantly directed toward adolescents in general, with limited targeted outreach to high-risk or marginalized groups. This finding signals a critical equity gap, as vulnerable adolescents often require tailored interventions to overcome socioeconomic, cultural, or behavioral barriers to care. Overall, strengthening adolescent SRH services in Albania requires a comprehensive systems approach that includes: (1) expansion of standardized adolescent-focused training programs; (2) improved coordination mechanisms between PHCs and NGOs; (3) enhancement of infrastructure and confidentiality safeguards; and (4) development of targeted strategies for high-risk and underserved adolescent populations. Embedding adolescent-responsive indicators into primary healthcare monitoring frameworks may further support accountability and quality improvement. By addressing workforce, structural, and coordination challenges simultaneously, policymakers and health system stakeholders can advance equitable, high-quality, and youth-friendly primary healthcare services that effectively respond to the evolving needs of adolescents. 6. Limitations Several limitations should be considered when interpreting the findings of this study. First, the cross-sectional design limits the ability to establish causal relationships between variables such as staff training, NGO support, and service quality. While statistically significant associations were identified, the temporal direction of these relationships cannot be confirmed. Second, the study relied on self-reported data from healthcare personnel. Responses may be subject to reporting bias, including social desirability bias, particularly in the assessment of service quality and institutional performance. Providers may have overestimated or underestimated service quality, training adequacy, or the extent of service provision. Third, although three districts representing urban and rural contexts were included, the findings may not be fully generalizable to all regions of Albania, particularly areas with different socioeconomic profiles or health system structures. Nonetheless, the inclusion of diverse settings strengthens the relevance of the results for similar primary care contexts Despite these limitations, the study provides valuable empirical evidence on the organization, capacity, and perceived quality of adolescent health services in Albanian primary healthcare centers and offers important directions for policy and system-level improvements. Declarations Acknowledgments The authors would like to thank all healthcare professionals who participated in this study for their time and valuable contributions. Author Contributions Zamira Cabiri: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Writing – original draft; Writing – review & editing; Brunilda Mehilli: Methodology; Validation; Supervision; Writing – review & editing; Gjergji Koja, Rajmonda Hida: Formal analysis; Data interpretation; Writing – review & editing; Elvira Dode: Investigation; Data collection; Data curation; Writing – review & editing; Arkida Skenderi, Elvira Qosja: Supervision; Project administration; Writing – review & editing. All authors have read and agreed to the published version of the manuscript. Funding This research was funded by NASRI (National Agency for Scientific Research, Technology and Innovation) in Albania. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to institutional data protection policies and confidentiality agreements with participating primary healthcare centers. However, anonymized data may be made available from the corresponding author upon reasonable request and with permission from the relevant institutional authorities. Ethics declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of the University of Elbasan “Aleksander Xhuvani” (protocol no. 880, date 06.04.2025). All participants were informed about the purpose of the study, assured of confidentiality, and provided written informed consent before participation. Consent for Publication Not applicable. The manuscript does not contain any individual-level identifiable data. Competing Interests The authors declare that they have no competing interests. There are no financial, personal, or professional conflicts that could have influenced the work reported in this study. Clinical trial number: not applicable References World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Geneva: WHO; 2017. United Nations Population Fund (UNFPA). Adolescent and Youth Sexual and Reproductive Health Strategy (2015–2025). New York: UNFPA; 2016. World Health Organization. Adolescent sexual and reproductive health: Evidence brief. Geneva: WHO; 2019. World Health Organization. Global Standards for Quality Health-Care Services for Adolescents. Geneva: WHO; 2015. Denno DM, Hoopes AJ, Chandra-Mouli V. Effective strategies to provide adolescent sexual and reproductive health services and increase demand and community support. J Adolesc Health. 2015;56(1):S22–41. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet Child Adolesc Health. 2017;1(2):e14–6. Baltag V, Sawyer SM. Quality health care for adolescents. In: International Handbook on Adolescent Health and Development. 2017. World Health Organization. Implementing adolescent-friendly health services: global standards in practice. Geneva: WHO; 2018. Ambresin AE, Bennett K, Patton GC, Sanci LA, Sawyer SM. Assessment of youth-friendly health care: a systematic review. Lancet Glob Health. 2017;5(5):e513–24. United Nations Children’s Fund (UNICEF). Adolescent health and well-being: Global progress report. New York: UNICEF; 2021. Ministry of Health and Social. Protection, Albania. National Action Plan for Sexual and Reproductive Health 2022–2030. Tirana; 2022. Chandra-Mouli V, Akwara E. Improving access to adolescent sexual and reproductive health services: lessons from NGO–government collaboration. Reprod Health. 2015;12:66. Ivanova O, Rai M, Kemigisha E. A systematic review of NGO-led adolescent SRH interventions in LMICs. BMC Public Health. 2018;18:476. United Nations Population Fund (UNFPA). Partnering with civil society to advance adolescent SRH. New York: UNFPA; 2020. Baltag V, et al. Adolescent health services in primary care: global challenges and opportunities. Lancet Child Adolesc Health. 2017;1(2):e14–6. Pahari S, Acharya SR, Pokhrel A, et al. Adolescent-friendly health services in Nepal: usage and key determinants. BMC Health Serv Res. 2025;25:1000. https://doi.org/10.1186/s12913-025-13157-y . Akila D, et al. Improving the Quality of Adolescent and Youth-Friendly Sexual and Reproductive Health Services through Capacity-Strengthening Approaches. Global Health: Science and Practice (Supplement; 2024. Chandra-Mouli V, Lane C, Wong S. What does not work in adolescent sexual and reproductive health: a review of evidence. J Adolesc Health. 2015;56:S10–4. Werdhani RA, Wanda D, Surasno HMF, et al. Adolescent and young adult-friendly primary health care services in low- and middle-income countries: a scoping review. Discov Soc Sci Health. 2025;5:7. https://doi.org/10.1007/s44155-025-00150-3 . Tilahun BD, Yilak G, Amena S, Abebe GK, Ayele M. Exploring the perceptions of health service providers and adolescents on the utilization of adolescent sexual and reproductive health services in Tikur, 2023: A qualitative study. SAGE Open Med. 2024;12:20503121231223660. PMID: 38249945; PMCID: PMC10798077. COMMITTEE ON ADOLESCENCE. Achieving Quality Health Services for Adolescents. Pediatrics. 2016;138(2):e20161347. 10.1542/peds.2016-1347 . Epub 2016 Jul 18. PMID: 27432849. Sanyang Y, Sanyang S, Ladur AN, et al. Are facility service delivery models meeting the sexual and reproductive health needs of adolescents in Sub-Saharan Africa? A qualitative evidence synthesis. BMC Health Serv Res. 2025;25:193. https://doi.org/10.1186/s12913-025-12344-1 . Chandra-Mouli V, Lane C, Wong S, Amin A. (2024). Reaching the most vulnerable adolescents: Evidence on targeted sexual and reproductive health interventions. Global Health: Sci Pract, 12(S2), e2300212. Sidamo NB, Kerbo AA, Gidebo KD, Wado YD. Exploring Barriers to Accessing Adolescents Sexual and Reproductive Health Services in South Ethiopia Regional State: A Phenomenological Study Using Levesque's Framework. Adolesc Health Med Ther. 2024;15:45–61. PMID: 38562442; PMCID: PMC10984202. World Health Organization & UNFPA. Strengthening health systems to respond to adolescents. Geneva: WHO; 2022. World Health Organization. Delivering quality health services for adolescents: a global standards implementation guide. Geneva: WHO; 2019. Ivanova O, Rai M, Kemigisha E. A systematic review of NGO-led adolescent sexual and reproductive health interventions in low- and middle-income countries. BMC Public Health. 2018;18:476. Khatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, Assefa Y. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23(1):750. 10.1186/s12913-023-09718-8 . PMID: 37443006; PMCID: PMC10339603. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8980193","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":616492739,"identity":"32deb0e0-6678-4a36-b4c0-05404bdcb6c0","order_by":0,"name":"Zamira Cabiri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIie3PMUsDMRQH8BcC1+XsrZkuX6E31w+TTJ3qIpQOHd5xkFtKXQ8U/QqK4NwQqIOls6CDxVmoi3RR+nJ0Ee5aR4f8ISGB9+OfAISE/NPM610wBDUGiICj3wE6fyJLP8z2hB/rErSY8acjRJZP2o0nIJPLwmzW1+6s28kRNiMHSdFM2HR4a5cLyKpXW1T6wZ1HsUVWrRwI10w4EMEIFDzrAohoIzTyE0PzLSRKPoj8gJI1uSIi18i/icgWEgtqyQ2oXk3QtzDkjEivhQhBLflMZHf0F1CLgTaxRjtdDeKshciL4f0nfp3K9KV8Z9tJX9+Uzr5tR/00fcRmsy/7fZ37Jx+aDwkJCQk5nB3E0GK9y4k/zQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":true,"prefix":"","firstName":"Zamira","middleName":"","lastName":"Cabiri","suffix":""},{"id":616492740,"identity":"c46ec4d0-286a-4a75-b6cb-19a4dfb2cef1","order_by":1,"name":"Brunilda Mehilli","email":"","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":false,"prefix":"","firstName":"Brunilda","middleName":"","lastName":"Mehilli","suffix":""},{"id":616492741,"identity":"f424a31b-62ed-4d45-9c5b-6ed750c45b0e","order_by":2,"name":"Gjergji Koja","email":"","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":false,"prefix":"","firstName":"Gjergji","middleName":"","lastName":"Koja","suffix":""},{"id":616492742,"identity":"8ffaece5-a95f-4765-a008-f9859ab67ba8","order_by":3,"name":"Elvira Dode","email":"","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":false,"prefix":"","firstName":"Elvira","middleName":"","lastName":"Dode","suffix":""},{"id":616492743,"identity":"f8207df1-5fcf-4cfd-99c2-9f1046819651","order_by":4,"name":"Arkida Skenderi","email":"","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":false,"prefix":"","firstName":"Arkida","middleName":"","lastName":"Skenderi","suffix":""},{"id":616492744,"identity":"cb5430d3-895d-4b8d-8365-f6ec902a94bc","order_by":5,"name":"Rajmonda Hida","email":"","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":false,"prefix":"","firstName":"Rajmonda","middleName":"","lastName":"Hida","suffix":""},{"id":616492747,"identity":"7e7c542a-ce92-4ea4-aefe-4580fb4ae43d","order_by":6,"name":"Elvira Qosja","email":"","orcid":"","institution":"University of Elbasan “Aleksandër Xhuvani”","correspondingAuthor":false,"prefix":"","firstName":"Elvira","middleName":"","lastName":"Qosja","suffix":""}],"badges":[],"createdAt":"2026-02-26 16:55:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8980193/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8980193/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106403523,"identity":"18f5bdb7-faff-4e23-bc49-5629654df82b","added_by":"auto","created_at":"2026-04-08 09:14:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1154305,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8980193/v1/b15fbd2c-d14f-40dd-a567-9cf8138d7989.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adolescent Health Services in Primary Health Care and Providers’ Perspectives on Access, Quality, and Utilisation Gaps","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAdolescence represents a critical window for sexual and reproductive health (SRH) interventions, as young people face elevated risks of sexually transmitted infections (STIs), unintended pregnancy, sexual violence, and mental health vulnerabilities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Primary healthcare (PHC) services play a pivotal role in addressing these needs through prevention, counseling, early diagnosis, and referral pathways.\u003c/p\u003e \u003cp\u003eDespite global recognition of adolescent SRH as a public health priority, substantial gaps persist in the availability, accessibility, and quality of adolescent-responsive services within primary care settings [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recent international evidence indicates that adolescents frequently encounter structural and interpersonal barriers when seeking care, including lack of privacy, limited confidentiality safeguards, judgmental provider attitudes, and inadequate youth engagement strategies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These challenges are more pronounced in low- and middle-income countries, where systemic constraints such as insufficient infrastructure, shortages of trained personnel, fragmented service organization, and weak referral mechanisms undermine the implementation of youth-friendly standards [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealthcare providers\u0026rsquo; competencies, attitudes, and institutional support systems play a critical role in shaping adolescents\u0026rsquo; healthcare utilization. Evidence from the past decade indicates that provider training in adolescent-centered communication, confidentiality, and non-discriminatory practices is positively associated with increased service uptake and improved perceived quality of care among adolescents [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In contrast, inadequate training and weak institutional frameworks may reinforce stigma and act as barriers to access, particularly for adolescents from vulnerable or marginalized populations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Albania, adolescent SRH has gained increasing policy attention in recent years. The National Action Plan for Sexual and Reproductive Health 2022\u0026ndash;2030 prioritizes the expansion of adolescent-friendly services, enhancement of confidentiality standards, reduction of stigma, and strengthening of intersectoral collaboration, especially in rural and underserved areas [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, empirical evidence assessing the implementation of these strategic objectives at the primary healthcare level remains limited. Existing national studies have primarily focused on general SRH indicators and population-level outcomes, offering limited insight into service organization, provider perspectives, training coverage, and the practical integration of adolescent-friendly approaches in PHCs.\u003c/p\u003e \u003cp\u003eFurthermore, the contribution of non-governmental organizations (NGOs) in complementing public primary healthcare (PHC) services through capacity building, community outreach, awareness campaigns, and targeted interventions for high-risk adolescent populations has not been systematically examined in the Albanian context. International evidence indicates that structured NGO engagement can expand service coverage, strengthen provider competencies, and improve access for marginalized adolescents when effectively integrated within public health systems [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, fragmented coordination mechanisms and limited institutional integration may undermine the sustainability and long-term impact of such initiatives.\u003c/p\u003e \u003cp\u003eGiven these knowledge gaps, this study aims to assess the provision of adolescent health services in primary healthcare centers in Albania. Specifically, it examines: (1) the availability and delivery of adolescent-friendly services; (2) healthcare providers\u0026rsquo; perceptions of service quality; (3) barriers related to training, institutional support, and resource availability; and (4) the role of NGO involvement in strengthening adolescent SRH services across urban and rural settings. By providing empirical evidence from frontline healthcare staff, this study seeks to inform policy implementation and support the development of more equitable, coordinated, and youth-responsive primary healthcare services.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eA cross-sectional survey design was employed to assess the availability, delivery, and perceived quality of adolescent sexual and reproductive health (SRH) services in primary healthcare centers (PHCs) in Albania. The study also examined the role of non-governmental organizations (NGOs) and identified barriers encountered by healthcare staff. Cross-sectional methodology allowed for the collection of quantitative data from multiple districts simultaneously to provide a comprehensive overview of service provision and staff perceptions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study Setting and Population\u003c/h2\u003e \u003cp\u003eThe study was conducted in three Albanian districts: Elbasan, Shkoder, and Durres. These districts were selected to represent both urban and rural primary healthcare settings, capturing variability in service delivery models, access, and population characteristics. The target population included healthcare staff working in PHCs, including physicians, nurses, midwives, and administrative staff involved in adolescent health service provision.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Sampling Strategy and Sample Size\u003c/h2\u003e \u003cp\u003eA stratified random sampling approach was employed to recruit participants across the three districts. Each primary healthcare center (PHC) was considered a stratum to ensure proportional representation of both urban and rural facilities. A total of 399 healthcare providers participated in the study. The sample size was calculated to ensure adequate statistical power to detect significant associations between staff training, service delivery characteristics, and perceived service quality, assuming a 95% confidence level and a 5% margin of error.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHealthcare staff employed at PHCs in the selected districts.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStaff involved directly or indirectly in the provision of adolescent health services.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWillingness to participate and provide informed consent.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStaff on temporary leave or absent during the data collection period.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePersonnel not involved in adolescent health service provision.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Collection Instrument and Procedure\u003c/h2\u003e \u003cp\u003eData were collected using a structured, self-administered questionnaire developed based on WHO guidelines for adolescent-friendly health services and existing literature on adolescent SRH in primary care [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The instrument included sections on:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSocio-demographic characteristics and professional experience.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eService delivery models by facility type and area (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStaff training and provider distribution (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTargeted adolescent populations (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerceived service quality and suggested improvements (Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBarriers to service provision (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePresence of NGO-led adolescent SRH projects (Tables\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eQuestionnaires were administered in person by trained research assistants. Participants completed the questionnaires anonymously during working hours. Clarifications were provided when necessary to minimize potential misunderstandings and ensure consistency in responses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Reliability and Validity\u003c/h2\u003e \u003cp\u003eThe questionnaire was pre-tested among a small sample of PHC staff (n\u0026thinsp;=\u0026thinsp;20) outside the study districts to assess clarity, relevance, and comprehension. Internal consistency of Likert-scale items (e.g., perceived service quality) was evaluated using Cronbach\u0026rsquo;s alpha, with a threshold of \u0026ge;\u0026thinsp;0.7 considered acceptable. Content validity was ensured through expert review by public health specialists and adolescent SRH experts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Ethical Considerations\u003c/h2\u003e \u003cp\u003eThe study protocol was reviewed and approved by the Ethics Committee of the University of Elbasan \u0026ldquo;Aleksander Xhuvani\u0026rdquo; (Protocol No. 880), which served as the coordinating institution for the project. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e \u003cp\u003eParticipation was voluntary, and strict confidentiality was maintained throughout the study. All data were anonymized prior to analysis and stored securely in accordance with institutional data protection policies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Statistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were computed to summarize frequencies, percentages, and cumulative distributions of responses across all variables. Associations between categorical variables, such as staff training and service provision, urban/rural location, and perceived service quality, were examined using chi-square tests. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analyses were conducted using SPSS version 26.0.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.9 Data Management and Quality Assurance\u003c/h2\u003e \u003cp\u003eCompleted questionnaires were checked for completeness and consistency before data entry. Double-entry procedures were applied to minimize data entry errors. Missing or ambiguous responses were cross-verified with field notes where possible. Ongoing supervision by the research team was implemented to maintain consistency and ensure compliance with standardized data collection procedures across all districts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.10 Clinical Trial Registration\u003c/h2\u003e \u003cp\u003eThis study was observational and did not involve clinical interventions; therefore, it was not registered as a clinical trial. The study adhered to the STROBE guidelines for observational studies to ensure methodological rigor and transparency in reporting.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Distribution of adolescent health service delivery by area (urban and rural)\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the distribution of adolescent health service delivery models according to geographic area (urban vs rural).\u003c/p\u003e \u003cp\u003eIn rural areas, adolescent health services were more frequently delivered through village clinics (n\u0026thinsp;=\u0026thinsp;100) and health centers (n\u0026thinsp;=\u0026thinsp;129), with limited provision at neighborhood clinics (n\u0026thinsp;=\u0026thinsp;12). In contrast, in urban areas, services were predominantly concentrated at health centers (n\u0026thinsp;=\u0026thinsp;138), while only a small number were delivered at village clinics (n\u0026thinsp;=\u0026thinsp;7) or neighborhood clinics (n\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003cp\u003eThe association between geographic area and service delivery point was statistically significant (χ\u0026sup2; = 66.800, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a clear structural difference in how adolescent services are organized across rural and urban settings.\u003c/p\u003e \u003cp\u003eThese findings suggest that rural service provision relies more heavily on decentralized village clinics in addition to health centers, reflecting the need to ensure geographic accessibility in areas with dispersed populations. Conversely, urban areas appear to centralize adolescent service delivery primarily within health centers, potentially benefiting from greater infrastructure concentration but possibly limiting accessibility for adolescents who face transportation, social, or confidentiality barriers.\u003c/p\u003e \u003cp\u003eThe statistically significant disparity highlights structural inequalities in service organization between rural and urban settings. While rural decentralization may improve physical access, it may also raise concerns regarding staffing capacity, availability of trained staff, and confidentiality in smaller community-based facilities. In urban areas, service centralization may enhance resource concentration but could inadvertently reduce outreach to vulnerable or marginalized adolescents who may not routinely access formal health centers.\u003c/p\u003e \u003cp\u003e Overall, these results underscore the importance of geographically tailored strategies to ensure equitable access to adolescent-friendly health services, with attention to both structural accessibility and quality-of-care standards across different service delivery points.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of adolescent health service delivery by area (urban and rural)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eIs this service provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAt the village clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAt the neighborhood clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly at the Health Center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eArea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural Area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003cp\u003eχ\u0026sup2; = 66.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban Area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e3.2. Number of trained staff and distribution of providers delivering adolescent sexual and reproductive health services in PHCs\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the association between the number of trained staff in adolescent sexual and reproductive health (SRH) and the number of providers delivering these services within primary healthcare centers (PHCs).\u003c/p\u003e \u003cp\u003eA statistically significant association was observed between staff training and service delivery capacity (χ\u0026sup2; = 270.337, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). PHCs with only one trained staff member most commonly reported that adolescent SRH services were provided by a single provider (n\u0026thinsp;=\u0026thinsp;52), with limited multi-provider involvement. Similarly, centers with two trained staff members primarily reported service provision by two providers (n\u0026thinsp;=\u0026thinsp;40).\u003c/p\u003e \u003cp\u003eIn contrast, PHCs with several trained staff were substantially more likely to report that adolescent SRH services were delivered by several providers (n\u0026thinsp;=\u0026thinsp;72), indicating broader internal service coverage and potentially greater continuity of care.\u003c/p\u003e \u003cp\u003eCenters without trained staff most frequently reported the absence of adolescent SRH services (n\u0026thinsp;=\u0026thinsp;69). Nevertheless, a proportion of facilities lacking formally trained staff indicated that limited services were provided by one or more healthcare providers. This finding suggests that adolescent SRH services may, in some instances, be delivered in the absence of specialized adolescent-focused training.\u003c/p\u003e \u003cp\u003eThese findings demonstrate a strong and direct relationship between training coverage and the scope of adolescent SRH service delivery. Facilities with a higher number of trained professionals appear better positioned to distribute service responsibilities among multiple providers, which may enhance accessibility, reduce service interruptions, and improve quality of care. Conversely, the absence of trained personnel is strongly associated with service non-provision, underscoring training as a critical determinant of service availability.\u003c/p\u003e \u003cp\u003eFrom a health systems perspective, the magnitude of the association (χ\u0026sup2; = 270.337) highlights staff capacity-building as a central structural factor influencing adolescent SRH service implementation in PHCs. Expanding training programs and ensuring equitable distribution of trained personnel across facilities may therefore represent a key strategy for strengthening adolescent-friendly service coverage and improving overall system responsiveness.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of trained staff and distribution of providers delivering adolescent sexual and reproductive health services in Primary Health Care Centers (PHCs)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eBy how many people is this service provided?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOne provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTwo providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSeveral providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eTrained staff for adolescent sexual and reproductive health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003cp\u003e\u003cb\u003eχ\u0026sup2; =270.337\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeveral providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Years of experience of primary healthcare staff\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the distribution of respondents according to their years of experience in primary healthcare.\u003c/p\u003e \u003cp\u003eThe largest proportion of participants reported 1\u0026ndash;5 years of professional experience (24.1%, n\u0026thinsp;=\u0026thinsp;96), followed by those with more than 20 years of experience (22.3%, n\u0026thinsp;=\u0026thinsp;89). Staff with 6\u0026ndash;10 years of experience accounted for 18.8% (n\u0026thinsp;=\u0026thinsp;75), while 17.3% (n\u0026thinsp;=\u0026thinsp;69) had 11\u0026ndash;15 years of service. Smaller proportions were observed among participants with less than 1 year of experience (10.0%, n\u0026thinsp;=\u0026thinsp;40) and those with 16\u0026ndash;20 years of experience (7.5%, n\u0026thinsp;=\u0026thinsp;30).\u003c/p\u003e \u003cp\u003eThe distribution indicates a relatively balanced workforce composition, combining early-career professionals with highly experienced personnel. Notably, nearly one quarter of respondents have more than two decades of experience, suggesting substantial institutional memory and long-standing engagement in primary care service delivery. At the same time, approximately one third of the sample (34.1%) consists of staff with five or fewer years of experience, reflecting generational renewal within the workforce.\u003c/p\u003e \u003cp\u003eFrom a health systems perspective, this heterogeneous experience profile has important implications for adolescent health service delivery. Early-career professionals may be more recently exposed to updated curricula and contemporary adolescent health frameworks, while highly experienced staff may rely more on accumulated clinical practice. However, as shown in previous analyses (Section 3.2), perceived training gaps were reported across all experience categories, indicating that both new and senior personnel may require continuous professional development in adolescent-specific competencies.\u003c/p\u003e \u003cp\u003eOverall, the experience distribution suggests that capacity-building strategies should be inclusive and tailored to different professional stages. Continuous in-service training, mentorship models combining senior and junior staff, and standardized adolescent-friendly service guidelines may help ensure consistent quality of care across diverse levels of professional experience.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eYears of experience of primary healthcare staff\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eValid Percent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCumulative Percent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eValid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOver 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Target adolescent groups for health service provision by districts\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the distribution of primary healthcare staff responses regarding the adolescent groups targeted by health services across the districts of Elbasan, Shkoder, and Durres.\u003c/p\u003e \u003cp\u003e The majority of respondents (74.2%, n\u0026thinsp;=\u0026thinsp;296) reported that services are provided to adolescents in general, without specific targeting of high-risk or marginalized populations. A smaller proportion of staff indicated that services were directed at multiple groups, either selecting more than one option (17.0%, n\u0026thinsp;=\u0026thinsp;68) or all of the above (5.0%, n\u0026thinsp;=\u0026thinsp;20).\u003c/p\u003e \u003cp\u003eTargeted service provision for high-risk or marginalized adolescent groups was notably limited. Only 2.5% of respondents reported delivering services specifically to adolescents engaging in high-risk behaviors (n\u0026thinsp;=\u0026thinsp;10), while 0.2% reported targeting adolescents from ethnic minority communities (n\u0026thinsp;=\u0026thinsp;1) and 0.2% those from socioeconomically disadvantaged families (n\u0026thinsp;=\u0026thinsp;1). This distribution was consistent across all three districts, with only minor variations in absolute numbers.\u003c/p\u003e \u003cp\u003eThese findings indicate that adolescent health services within Albanian PHCs are predominantly generalized in scope and may insufficiently address the distinct needs of vulnerable or high-risk populations. The limited implementation of targeted interventions suggests a potential gap in service equity and inclusiveness, which may contribute to persistent disparities in sexual and reproductive health outcomes.\u003c/p\u003e \u003cp\u003eThese results highlight the importance of designing and integrating targeted, equity-oriented strategies within primary healthcare services to better reach adolescents at heightened risk, including those engaging in high-risk behaviors, from marginalized ethnic communities, or experiencing socioeconomic disadvantage. Strengthening outreach programs, tailoring service delivery to specific populations, and integrating social determinants of health into adolescent care planning could enhance service equity, accessibility, and effectiveness across different districts.\u003c/p\u003e \u003cp\u003eOverall, the findings underscore the importance of complementing generalized adolescent health services with targeted interventions to ensure that high-risk and marginalized groups are not overlooked in primary healthcare provision.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTarget adolescent groups for health service provision by districts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eElbasan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShkoder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDurres\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eWhich group (or groups) of adolescents do you aim to provide health services to?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoung people with risky behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10(2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoung people from ethnic communities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoung people from socioeconomically disadvantaged families\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoung people in general\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140(35.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77(19.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79(19.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e296(74.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll of the above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20(5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than one option\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(5.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24(6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68(17.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Assessment of adolescent health service quality by districts\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents healthcare staff\u0026rsquo;s assessment of the quality of adolescent health services across three Albanian districts: Elbasan, Shkoder, and Durres.\u003c/p\u003e \u003cp\u003eOverall, the majority of respondents rated service quality as good (26.7%, n\u0026thinsp;=\u0026thinsp;107) or very good (36.3%, n\u0026thinsp;=\u0026thinsp;145), indicating a generally positive perception of adolescent health service delivery. Services were rated as average by 21.8% of participants (n\u0026thinsp;=\u0026thinsp;87), while only a minority of respondents assessed services as poor (7.7%, n\u0026thinsp;=\u0026thinsp;31) or very poor (7.2%, n\u0026thinsp;=\u0026thinsp;29).\u003c/p\u003e \u003cp\u003eDistrict-level comparisons reveal variability in perceived service quality. Elbasan had the highest proportion of respondents rating services as very good (17.3%, n\u0026thinsp;=\u0026thinsp;69), while Shkodra had a lower proportion in this category (8.5%, n\u0026thinsp;=\u0026thinsp;34). Durres showed a relatively balanced distribution across good (9.5%, n\u0026thinsp;=\u0026thinsp;38) and very good (10.5%, n\u0026thinsp;=\u0026thinsp;42) ratings. Similarly, Elbasan reported slightly higher frequencies of average ratings (9.8%, n\u0026thinsp;=\u0026thinsp;39) compared to the other districts.\u003c/p\u003e \u003cp\u003eThe observed differences may reflect variations in resource allocation, staff capacity, training coverage, infrastructure, or the presence of NGO-supported initiatives across districts. For instance, districts with higher concentrations of trained staff or better coordination with NGOs may contribute to elevated perceptions of service quality. Conversely, districts with fewer trained staff or limited facility infrastructure may experience lower perceived service performance.\u003c/p\u003e \u003cp\u003eThese findings highlight that, while overall perceptions are positive, district-level disparities persist, suggesting the need for targeted interventions to ensure equitable quality of adolescent health services across different geographic regions. Policy strategies could include harmonizing staff training programs, standardizing adolescent-friendly service protocols, and facilitating inter-district sharing of best practices to reduce quality variation.\u003c/p\u003e \u003cp\u003eIn conclusion, the results emphasize both overall satisfaction with service provision and the importance of addressing local disparities to achieve consistent, high-quality, and youth-responsive primary healthcare for adolescents across Albania.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssessment of adolescent health service quality by districts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eElbasan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShkoder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDurres\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAssessment of the quality of services provided for adolescents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery poor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6(1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29(7.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9(2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31(7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22(5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87(21.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38(9.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e107(26.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69(17.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42(10.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e145(36.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.6. Assessment of adolescent health service quality and suggestions for improvement in primary healthcare centers\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents the association between healthcare staff\u0026rsquo;s assessment of the quality of adolescent health services and their proposed strategies for service improvement.\u003c/p\u003e \u003cp\u003eA statistically significant association was identified between perceived service quality and suggested improvement measures (χ\u0026sup2; = 54.309, p\u0026thinsp;=\u0026thinsp;0.002), indicating that staff perceptions of quality meaningfully influenced their proposed priorities for strengthening services.\u003c/p\u003e \u003cp\u003eAmong respondents who rated services as very poor or poor, improvement strategies were more frequently focused on staff training, promotion of health education, and selecting more than one option, reflecting recognition of multiple systemic weaknesses. In particular, staff who perceived services as very poor most commonly emphasized training (2.0%) and multiple combined interventions (2.5%).\u003c/p\u003e \u003cp\u003eParticipants who rated services as average most frequently prioritized staff training (3.7%) and the selection of multiple improvement strategies (11.3%). This pattern suggests that even when service performance is perceived as moderate, respondents recognize the need for comprehensive and multifaceted strengthening efforts.\u003c/p\u003e \u003cp\u003eAmong those who rated services as good or very good, responses were more diverse. Staff in these categories frequently selected promotion of health education, creating a suitable environment, and ensuring privacy and confidentiality. Notably, respondents who rated services as very good still identified multiple areas for improvement, particularly health education promotion (7.5%) and combined strategies (13.8%), indicating ongoing awareness of optimization needs even within relatively well-performing centers.\u003c/p\u003e \u003cp\u003eAcross all quality categories, selecting \u0026ldquo;\u003cem\u003emore than one option\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eall of the above\u003c/em\u003e\u0026rdquo; was common, reinforcing the perception that improving adolescent health services requires comprehensive interventions rather than isolated measures. Although options such as use of technology and social media and adapting service hours were selected less frequently, their presence indicates growing recognition of innovative and youth-centered approaches.\u003c/p\u003e \u003cp\u003eFrom a health systems perspective, the observed association between perceived service quality and proposed improvement strategies underscores the value of incorporating frontline provider perspectives into service planning and quality improvement processes. Providers who perceived lower service quality were more likely to prioritize structural capacity-building measures, particularly staff training. In contrast, those reporting higher perceived quality tended to emphasize enhancements related to the service environment and confidentiality practices.\u003c/p\u003e \u003cp\u003eOverall, the findings suggest that strengthening adolescent health services in primary healthcare centers requires integrated strategies that combine workforce training, infrastructure improvements, confidentiality safeguards, community health education, and modernization of service delivery approaches. The statistically significant relationship between quality perception and proposed interventions underscores the need to incorporate healthcare provider feedback into adolescent health policy and program development.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssessment of adolescent health service quality and suggestions for improvement in primary health care centers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e \u003cp\u003eHow could adolescent services be improved at your health center?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePromotion of health education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCreating a suitable environment for this service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTraining of staff to provide this service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnsuring privacy and confidentiality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUse of technology and social media\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdapting service hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAll of the above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMore than one option\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eHow would you rate the quality of the services you provide for adolescents?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery poor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10(2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003cp\u003e\u003cb\u003eχ\u0026sup2; =54.309\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12(3.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15(3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4(1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e45 ( 11.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(4.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6(1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4(1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e50(12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18(4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9(2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7(1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e55(13.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.7. Barriers to providing adolescent health services according to years of primary care staff experience\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e presents the distribution of perceived barriers to adolescent health service provision according to years of experience in primary care.\u003c/p\u003e \u003cp\u003eOverall, the most frequently reported barrier was lack of training and specific skills for adolescents (32.8%, n\u0026thinsp;=\u0026thinsp;131). This concern was reported across all experience categories, with relatively higher frequencies among staff with 1\u0026ndash;5 years (7.5%) and over 20 years of experience (7.3%). These findings suggest that insufficient adolescent-specific competencies are perceived as a systemic issue, affecting both early-career and highly experienced professionals.\u003c/p\u003e \u003cp\u003eThe second most commonly reported category was \u0026ldquo;\u003cem\u003eOther\u003c/em\u003e\u0026rdquo; barriers (32.6%, n\u0026thinsp;=\u0026thinsp;130), followed by selecting more than one option (16.0%, n\u0026thinsp;=\u0026thinsp;64), indicating that many respondents perceive barriers as multifactorial rather than isolated. Lack of resources and infrastructure was identified by 13.0% (n\u0026thinsp;=\u0026thinsp;52) of participants and was reported consistently across experience groups, though slightly more frequently among those with over 20 years of service (3.5%).\u003c/p\u003e \u003cp\u003eIn contrast, lack of communication ethics (1.8%, n\u0026thinsp;=\u0026thinsp;7) and the cultural norms and values of healthcare personnel (1.5%, n\u0026thinsp;=\u0026thinsp;6) were less frequently identified as primary barriers. This pattern may suggest that respondents perceive structural and capacity-related constraints as more significant impediments to service provision than interpersonal or attitudinal factors.\u003c/p\u003e \u003cp\u003eNotably, both early-career professionals (\u0026le;\u0026thinsp;1 year and 1\u0026ndash;5 years of experience) and those with more than 20 years of service reported training deficits at comparable levels. This finding suggests that gaps in adolescent-specific competencies may not be sufficiently addressed through either pre-service education or continuing professional development. Mid-career staff (6\u0026ndash;15 years of experience) also frequently identified resource limitations and skills-related barriers, further indicating that systemic constraints persist across different stages of professional practice.\u003c/p\u003e \u003cp\u003eFrom a health systems perspective, these findings underscore that workforce capacity-building remains a central challenge in strengthening adolescent health services in primary care. While infrastructure and resource limitations are notable, the predominance of training-related barriers highlights the need for structured, continuous, and adolescent-focused professional development programs. Additionally, the high proportion of respondents identifying multiple barriers suggests that effective improvement strategies should adopt a comprehensive approach addressing training, institutional support, and structural resource allocation simultaneously.\u003c/p\u003e \u003cp\u003eOverall, the results demonstrate that perceived barriers are widespread across all experience levels, indicating that strengthening adolescent health services requires system-wide interventions rather than targeted measures for specific staff cohorts.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers to providing adolescent health services according to years of primary care staff experience\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e \u003cp\u003eYears of work in primary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u0026ndash;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16\u0026ndash;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOver 20 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eIn your opinion, what are the barriers to providing health services for adolescents from the perspective of healthcare personnel?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of training and specific skills for adolescents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25(6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e29(7.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e131(32.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of communication ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7(1.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCultures and values of healthcare personnel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6(1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of resources and infrastructure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6(1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e52(13.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30(7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21(5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7(1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24(6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e130(32.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll of the above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3(0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9(2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than one option\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9(2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2(0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18(4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e64(16.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.8. NGO support in the provision of adolescent health services in primary healthcare centers\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e summarizes respondents\u0026rsquo; perceptions regarding direct NGO support for adolescent health service provision within primary healthcare centers (PHCs).\u003c/p\u003e \u003cp\u003e Only 15.5% (n\u0026thinsp;=\u0026thinsp;62) of participants reported receiving NGO support in delivering adolescent health services. In contrast, more than half of respondents (54.1%, n\u0026thinsp;=\u0026thinsp;216) indicated that their centers did not receive any NGO assistance. Additionally, 30.3% (n\u0026thinsp;=\u0026thinsp;121) stated that they were unaware of whether such support was provided.\u003c/p\u003e \u003cp\u003eThese findings suggest that NGO involvement in the direct strengthening of adolescent health services at the PHC level is limited. Compared with the presence of NGO-led educational projects (Section \u003cspan refid=\"Sec14\" class=\"InternalRef\"\u003e3.1\u003c/span\u003e), reported institutional support for service delivery appears even lower, indicating that NGO engagement may be more focused on community-based awareness activities rather than structural or capacity-building interventions within healthcare facilities.\u003c/p\u003e \u003cp\u003eThe high proportion of \u0026ldquo;\u003cem\u003eI don\u0026rsquo;t know\u003c/em\u003e\u0026rdquo; responses again points to potential communication gaps, insufficient coordination mechanisms, or limited integration of externally supported initiatives into routine PHC operations. Lack of awareness among staff may also reflect the absence of formal collaboration agreements, unclear roles and responsibilities, or minimal institutional visibility of NGO contributions.\u003c/p\u003e \u003cp\u003eFrom a health systems perspective, limited NGO support at the facility level may constrain opportunities for staff training, resource supplementation, outreach to vulnerable adolescent groups, and implementation of youth-friendly service standards. Strengthening formal partnerships between public primary care services and civil society organizations could enhance service coverage, improve quality of care, and support more targeted interventions for high-risk and marginalized adolescents.\u003c/p\u003e \u003cp\u003eOverall, the findings reinforce the need for structured intersectoral collaboration frameworks to ensure that NGO engagement effectively complements and strengthens primary healthcare delivery for adolescents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNGO support in the provision of adolescent health services in primary health care centers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eValid Percent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCumulative Percent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eValid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.9. Participation in NGO-led projects for adolescent sexual and reproductive health education\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e presents the distribution of responses regarding the presence of non-governmental organization (NGO)-led projects focused on adolescent sexual and reproductive health (SRH) information and education in the respondents\u0026rsquo; service areas.\u003c/p\u003e \u003cp\u003eOnly 19.3% (n\u0026thinsp;=\u0026thinsp;77) of primary healthcare staff reported the presence of NGO-supported adolescent SRH initiatives in their area. In contrast, nearly half of respondents (49.9%, n\u0026thinsp;=\u0026thinsp;199) indicated that no such projects were being implemented. Additionally, 30.8% (n\u0026thinsp;=\u0026thinsp;123) reported being unaware of whether NGO-led activities existed locally.\u003c/p\u003e \u003cp\u003eThese findings indicate limited integration and/or visibility of NGO-led adolescent SRH education initiatives within primary healthcare catchment areas. The relatively low proportion of confirmed NGO participation suggests that civil society engagement in adolescent SRH may be geographically restricted, project-based, or inconsistently coordinated with public sector services.\u003c/p\u003e \u003cp\u003eImportantly, the high percentage of respondents who were unaware of NGO activities points to potential gaps in communication and institutional collaboration between NGOs and primary healthcare centers (PHCs). Such gaps may hinder effective referral mechanisms, reduce opportunities for joint outreach activities, and limit the continuity of adolescent-focused preventive and educational interventions.\u003c/p\u003e \u003cp\u003eOverall, the results highlight fragmentation between public primary healthcare services and external stakeholders involved in adolescent SRH education. Strengthening structured collaboration frameworks, improving information-sharing mechanisms, and enhancing staff awareness of community-based initiatives may contribute to more coordinated, comprehensive, and youth-responsive service delivery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipation of NGOs in projects for adolescent sexual and reproductive health information and education in the area\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eValid Percent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCumulative Percent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eValid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eGeographical disparities in service delivery models were also evident, with rural areas relying more heavily on village clinics and urban services concentrated in health centers. Similar rural-urban discrepancies have been reported in other middle-income countries, where decentralization improves physical accessibility but may compromise confidentiality, staffing capacity, and resource availability [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Ensuring equitable adolescent-friendly services requires context-adapted strategies that balance accessibility with quality standards, including privacy safeguards and adequately trained personnel [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWorkforce training emerged as one of the most significant determinants of service provision. The strong statistical association between the number of trained staff and the availability of adolescent SRH services confirms that provider capacity is central to effective implementation. Recent evidence consistently demonstrates that healthcare providers trained in adolescent-friendly communication, confidentiality, and non-judgmental care are more likely to deliver comprehensive services and improve adolescents\u0026rsquo; willingness to seek care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Conversely, inadequate training remains one of the most frequently cited barriers in low- and middle-income countries, contributing to reduced service uptake and suboptimal quality of care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe barriers identified by participants, including insufficient training, limited resources, and infrastructural constraints, are consistent with findings from comparable health systems, where structural weaknesses impede the effective delivery of adolescent services [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although interpersonal barriers, such as provider attitudes, were less frequently reported in the present study, international evidence indicates that these factors may nonetheless shape adolescents\u0026rsquo; care-seeking experiences, particularly in sensitive domains such as sexual and reproductive health [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The consistent reporting of training gaps across all levels of professional experience further suggests that both pre-service education and continuing professional development programs require strengthening.\u003c/p\u003e \u003cp\u003ePerceived service quality significantly influenced proposed improvement strategies. Staff who rated services as poor prioritized training and educational promotion, whereas those who perceived higher quality emphasized environmental enhancements, privacy, and confidentiality measures. This reflects the multidimensional nature of quality in adolescent healthcare, encompassing technical competence, communication skills, confidentiality, and youth-centered service environments [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Adolescents consistently identify respectful communication, privacy, and trust as decisive factors in service utilization, reinforcing the importance of maintaining confidentiality standards within PHCs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA particularly important finding concerns the limited targeting of high-risk or marginalized adolescent groups. Most services were reported to address adolescents in general, with minimal focus on young people with risky behaviors, those from low-income families, or ethnic minority communities. International literature highlights that universal service models, while essential, may fail to address disparities unless complemented by targeted outreach strategies for vulnerable populations [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Adolescents facing socioeconomic disadvantage or engaging in risk behaviors often encounter additional barriers to accessing SRH services, necessitating proactive, equity-oriented interventions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the findings underscore the need for comprehensive system-level strengthening of adolescent SRH services in Albania. International experience indicates that sustainable improvements require integrated strategies combining workforce training, infrastructure investment, standardized youth-friendly service protocols, and formalized NGO-government collaboration mechanisms [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Strengthening monitoring frameworks and embedding adolescent-responsive indicators within primary care performance evaluation systems may further enhance accountability and equity.\u003c/p\u003e \u003cp\u003eThis study provides comprehensive evidence on the status of adolescent sexual and reproductive health (SRH) services within primary healthcare centers (PHCs) in Albania, highlighting structural, workforce, and coordination-related challenges. The findings demonstrate that adolescent services remain unevenly implemented, insufficiently coordinated with non-governmental organizations (NGOs), and limited in targeted outreach to vulnerable groups. These results are consistent with international evidence indicating that, despite global prioritization of adolescent SRH, implementation gaps persist at the primary healthcare level [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe limited reported engagement of NGOs in both educational initiatives and direct PHC support suggests weak intersectoral coordination. Although NGOs often play a complementary role in strengthening adolescent SRH services through outreach, awareness campaigns, and provider capacity building, their impact depends heavily on structured collaboration with public health systems [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Fragmented partnerships and a lack of institutional integration can reduce sustainability and limit service continuity, particularly in decentralized primary care contexts [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The high proportion of respondents unaware of NGO activities further underscores potential communication and coordination deficiencies within the system.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis study highlights important structural and organizational gaps in the provision of adolescent sexual and reproductive health (SRH) services within primary healthcare centers (PHCs) in Albania. Although a considerable proportion of healthcare staff rated service quality as good or very good, the findings reveal significant inconsistencies in service availability, geographic distribution, workforce preparedness, and intersectoral collaboration.\u003c/p\u003e \u003cp\u003eThe limited presence and visibility of NGO-supported initiatives, combined with weak coordination between civil society and public primary care services, indicate missed opportunities for strengthening adolescent-focused outreach and capacity building. Furthermore, the strong association between staff training and service provision underscores the central role of workforce development in ensuring comprehensive and sustainable adolescent SRH services. Facilities with trained personnel were significantly more likely to provide services, while those without trained staff frequently reported service gaps.\u003c/p\u003e \u003cp\u003eGeographic disparities between rural and urban service delivery models suggest the need for context-specific strategies to ensure equitable access. While rural decentralization may enhance physical accessibility, it requires adequate staffing, confidentiality safeguards, and resource allocation to maintain service quality. Urban centralization, although potentially resource-efficient, should be complemented by youth-friendly adaptations to reduce social and structural barriers.\u003c/p\u003e \u003cp\u003eImportantly, services were predominantly directed toward adolescents in general, with limited targeted outreach to high-risk or marginalized groups. This finding signals a critical equity gap, as vulnerable adolescents often require tailored interventions to overcome socioeconomic, cultural, or behavioral barriers to care.\u003c/p\u003e \u003cp\u003eOverall, strengthening adolescent SRH services in Albania requires a comprehensive systems approach that includes: (1) expansion of standardized adolescent-focused training programs; (2) improved coordination mechanisms between PHCs and NGOs; (3) enhancement of infrastructure and confidentiality safeguards; and (4) development of targeted strategies for high-risk and underserved adolescent populations. Embedding adolescent-responsive indicators into primary healthcare monitoring frameworks may further support accountability and quality improvement.\u003c/p\u003e \u003cp\u003eBy addressing workforce, structural, and coordination challenges simultaneously, policymakers and health system stakeholders can advance equitable, high-quality, and youth-friendly primary healthcare services that effectively respond to the evolving needs of adolescents.\u003c/p\u003e"},{"header":"6. Limitations","content":"\u003cp\u003eSeveral limitations should be considered when interpreting the findings of this study.\u003c/p\u003e \u003cp\u003eFirst, the cross-sectional design limits the ability to establish causal relationships between variables such as staff training, NGO support, and service quality. While statistically significant associations were identified, the temporal direction of these relationships cannot be confirmed.\u003c/p\u003e \u003cp\u003eSecond, the study relied on self-reported data from healthcare personnel. Responses may be subject to reporting bias, including social desirability bias, particularly in the assessment of service quality and institutional performance. Providers may have overestimated or underestimated service quality, training adequacy, or the extent of service provision.\u003c/p\u003e \u003cp\u003eThird, although three districts representing urban and rural contexts were included, the findings may not be fully generalizable to all regions of Albania, particularly areas with different socioeconomic profiles or health system structures. Nonetheless, the inclusion of diverse settings strengthens the relevance of the results for similar primary care contexts\u003c/p\u003e \u003cp\u003eDespite these limitations, the study provides valuable empirical evidence on the organization, capacity, and perceived quality of adolescent health services in Albanian primary healthcare centers and offers important directions for policy and system-level improvements.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all healthcare professionals who participated in this study for their time and valuable contributions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZamira Cabiri: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp; editing; Brunilda Mehilli: Methodology; Validation; Supervision; Writing \u0026ndash; review \u0026amp; editing; Gjergji Koja, Rajmonda Hida: Formal analysis; Data interpretation; Writing \u0026ndash; review \u0026amp; editing; Elvira Dode: Investigation; Data collection; Data curation; Writing \u0026ndash; review \u0026amp; editing; Arkida Skenderi, Elvira Qosja: Supervision; Project administration; Writing \u0026ndash; review \u0026amp; editing. All authors have read and agreed to the published version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by NASRI (National Agency for Scientific Research, Technology and Innovation) in Albania.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional data protection policies and confidentiality agreements with participating primary healthcare centers. However, anonymized data may be made available from the corresponding author upon reasonable request and with permission from the relevant institutional authorities.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of the University of Elbasan \u0026ldquo;Aleksander Xhuvani\u0026rdquo; (protocol no. 880, date 06.04.2025). All participants were informed about the purpose of the study, assured of confidentiality, and provided written informed consent before participation.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any individual-level identifiable data.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. There are no financial, personal, or professional conflicts that could have influenced the work reported in this study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Geneva: WHO; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations Population Fund (UNFPA). Adolescent and Youth Sexual and Reproductive Health Strategy (2015\u0026ndash;2025). New York: UNFPA; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Adolescent sexual and reproductive health: Evidence brief. Geneva: WHO; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Standards for Quality Health-Care Services for Adolescents. Geneva: WHO; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenno DM, Hoopes AJ, Chandra-Mouli V. Effective strategies to provide adolescent sexual and reproductive health services and increase demand and community support. J Adolesc Health. 2015;56(1):S22\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet Child Adolesc Health. 2017;1(2):e14\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaltag V, Sawyer SM. Quality health care for adolescents. In: International Handbook on Adolescent Health and Development. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Implementing adolescent-friendly health services: global standards in practice. Geneva: WHO; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbresin AE, Bennett K, Patton GC, Sanci LA, Sawyer SM. Assessment of youth-friendly health care: a systematic review. Lancet Glob Health. 2017;5(5):e513\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations Children\u0026rsquo;s Fund (UNICEF). Adolescent health and well-being: Global progress report. New York: UNICEF; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health and Social. Protection, Albania. National Action Plan for Sexual and Reproductive Health 2022\u0026ndash;2030. Tirana; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandra-Mouli V, Akwara E. Improving access to adolescent sexual and reproductive health services: lessons from NGO\u0026ndash;government collaboration. Reprod Health. 2015;12:66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvanova O, Rai M, Kemigisha E. A systematic review of NGO-led adolescent SRH interventions in LMICs. BMC Public Health. 2018;18:476.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations Population Fund (UNFPA). Partnering with civil society to advance adolescent SRH. New York: UNFPA; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaltag V, et al. Adolescent health services in primary care: global challenges and opportunities. Lancet Child Adolesc Health. 2017;1(2):e14\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePahari S, Acharya SR, Pokhrel A, et al. Adolescent-friendly health services in Nepal: usage and key determinants. BMC Health Serv Res. 2025;25:1000. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-025-13157-y\u003c/span\u003e\u003cspan address=\"10.1186/s12913-025-13157-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkila D, et al. Improving the Quality of Adolescent and Youth-Friendly Sexual and Reproductive Health Services through Capacity-Strengthening Approaches. Global Health: Science and Practice (Supplement; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandra-Mouli V, Lane C, Wong S. What does not work in adolescent sexual and reproductive health: a review of evidence. J Adolesc Health. 2015;56:S10\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerdhani RA, Wanda D, Surasno HMF, et al. Adolescent and young adult-friendly primary health care services in low- and middle-income countries: a scoping review. Discov Soc Sci Health. 2025;5:7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s44155-025-00150-3\u003c/span\u003e\u003cspan address=\"10.1007/s44155-025-00150-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTilahun BD, Yilak G, Amena S, Abebe GK, Ayele M. Exploring the perceptions of health service providers and adolescents on the utilization of adolescent sexual and reproductive health services in Tikur, 2023: A qualitative study. SAGE Open Med. 2024;12:20503121231223660. PMID: 38249945; PMCID: PMC10798077.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCOMMITTEE ON ADOLESCENCE. Achieving Quality Health Services for Adolescents. Pediatrics. 2016;138(2):e20161347. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2016-1347\u003c/span\u003e\u003cspan address=\"10.1542/peds.2016-1347\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Jul 18. PMID: 27432849.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanyang Y, Sanyang S, Ladur AN, et al. Are facility service delivery models meeting the sexual and reproductive health needs of adolescents in Sub-Saharan Africa? A qualitative evidence synthesis. BMC Health Serv Res. 2025;25:193. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-025-12344-1\u003c/span\u003e\u003cspan address=\"10.1186/s12913-025-12344-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandra-Mouli V, Lane C, Wong S, Amin A. (2024). Reaching the most vulnerable adolescents: Evidence on targeted sexual and reproductive health interventions. Global Health: Sci Pract, 12(S2), e2300212.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSidamo NB, Kerbo AA, Gidebo KD, Wado YD. Exploring Barriers to Accessing Adolescents Sexual and Reproductive Health Services in South Ethiopia Regional State: A Phenomenological Study Using Levesque's Framework. Adolesc Health Med Ther. 2024;15:45\u0026ndash;61. PMID: 38562442; PMCID: PMC10984202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization \u0026amp; UNFPA. Strengthening health systems to respond to adolescents. Geneva: WHO; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Delivering quality health services for adolescents: a global standards implementation guide. Geneva: WHO; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvanova O, Rai M, Kemigisha E. A systematic review of NGO-led adolescent sexual and reproductive health interventions in low- and middle-income countries. BMC Public Health. 2018;18:476.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, Assefa Y. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23(1):750. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-023-09718-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-09718-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37443006; PMCID: PMC10339603.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent health, Primary care, SRH, NGO collaboration, training","lastPublishedDoi":"10.21203/rs.3.rs-8980193/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8980193/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAdolescent sexual and reproductive health (SRH) services constitute an essential component of comprehensive primary healthcare delivery. This study assessed the availability, delivery, and perceived quality of adolescent SRH services in Albanian primary healthcare centers, barriers faced by healthcare personnel and the role of NGOs.\u003c/p\u003e \u003cp\u003eA cross-sectional study was conducted among 399 healthcare professionals across three districts of Albania (Elbasan, Shkoder, and Durres). Data were collected on service provision, staff training, resource availability, and perceived quality of adolescent SRH services. Associations between training, service coverage, geographic location, and proposed improvement strategies were analyzed using chi-square tests.\u003c/p\u003e \u003cp\u003eService delivery varied significantly between rural and urban settings (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Staff training was strongly associated with broader SRH service coverage (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Key barriers to service provision included inadequate training, limited resources, and institutional constraints. Nurses were identified as the primary service providers. However, SRH services rarely targeted high-risk or marginalized adolescent populations. Perceived service quality was significantly associated with proposed improvement strategies (p\u0026thinsp;=\u0026thinsp;0.002). Only 19.3% of respondents reported the presence of NGO-led adolescent sexual and reproductive health (SRH) projects in their facilities, whereas 50% indicated no NGO involvement. Support from non-governmental organizations (NGOs) to primary health centers (PHCs) was limited, with only 15.5% reporting such assistance.\u003c/p\u003e \u003cp\u003eAdolescent SRH services in Albania remain fragmented and uneven. Strengthening staff training, enhancing coordination with NGOs, and developing targeted approaches for high-risk adolescent groups are essential to improve access, quality, and equity of adolescent SRH services.\u003c/p\u003e","manuscriptTitle":"Adolescent Health Services in Primary Health Care and Providers’ Perspectives on Access, Quality, and Utilisation Gaps","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 04:42:11","doi":"10.21203/rs.3.rs-8980193/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T13:03:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T04:53:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T20:08:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T11:41:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141722924611659092846057835928321669168","date":"2026-04-02T09:22:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226072436721494564407568199831637540309","date":"2026-04-02T04:21:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313875160560298884486015015344624347635","date":"2026-04-01T14:18:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203321841927839376087036750664150770169","date":"2026-04-01T13:49:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T11:19:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-23T15:32:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-23T15:31:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-26T16:45:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6ef4ec4-4566-41ac-b762-faa11a51abb2","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-29T13:03:23+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T05:23:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 04:42:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8980193","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8980193","identity":"rs-8980193","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}