Abstract
<title>Abstract</title> <p>Background Despite national policies promoting adolescent- and youth-friendly health services (YFHS), utilization remains low in many low- and middle-income countries, particularly among rural adolescents facing geographic, social, and confidentiality-related barriers. Ethiopia’s Health Extension Program offers an opportunity to decentralize YFHS through community health posts, but evidence on the implementation, quality, and utilization of this model remains limited. This study evaluated YFHS delivered through community health posts in Jimma Zone, Ethiopia, using the Donabedian quality-of-care framework complemented by Proctor’s Implementation Outcomes Framework. Methods A comparative explanatory mixed-methods study was conducted from January to March 2025 in five intervention and five comparison districts. Quantitative data were collected from 897 adolescents and young people aged 10–24 years, 66 client exit interviews, 30 health post observations, and Health Extension Worker assessments. Qualitative data were obtained through 22 key informant interviews and four focus group discussions. Service quality was assessed across structure, process, and outcome domains. Multivariable logistic regression identified factors associated with YFHS utilization, while thematic analysis explored implementation experiences, barriers, and facilitators. District-clustered robust standard errors were used in sensitivity analyses. Results Overall, 21.5% of participants reported utilizing at least one YFHS package during the previous 12 months. Utilization was higher in intervention than comparison districts (37.3% vs. 5.8%; p < 0.001). Intervention health posts demonstrated stronger structural readiness and higher process-quality indicators, including privacy, confidentiality, respectful communication, and counselling quality. More than 85% of service users reported positive care experiences. In multivariable analysis, intervention residence (AOR = 6.83, 95% CI: 4.00–11.68), youth programme participation (AOR = 9.36, 95% CI: 5.67–15.44), female sex (AOR = 2.29, 95% CI: 1.41–3.71), and marital status were independently associated with YFHS utilization. Qualitative findings indicated that trust in Health Extension Workers, confidentiality, youth engagement, supervision, and service proximity facilitated uptake, while limited awareness, stigma, and sociocultural norms remained barriers. Conclusions Integrating YFHS into community health posts may be a feasible strategy for improving service quality and utilization among adolescents and young people. Strengthening provider competencies, supervision, privacy-enhancing service organization, and youth engagement can support adolescent-responsive care within routine primary healthcare and offers a potentially scalable model for similar low-resource settings.</p>