Abstract Background Youth friendly services, an evidence based approach to overcome the barriers experienced by youths in accessing care, is poorly implemented. The Medical Women’s Association of Nigeria (MWAN) Rivers State chapter, was supported by Ford Foundation to mainstream youth-friendly health services (YFHS) into existing primary health care facilities in two hard-to-reach communities. This paper presents the interventions, findings, challenges and recommendations. Methods This study project was implemented in stages: design, baseline survey, interventions and evaluation, between 2014 and 2016. Interventions included facility modifications, health worker capacity building, school and community outreaches, peer group activities, and interpersonal communication. Pre-and-post-intervention surveys were carried out among in- and out-of-school youths to determine the effects of the interventions. Results The most commonly stated barriers to uptake of youth friendly health services included: unavailability of services (154; 33.1%), unavailability of health care workers (167; 38.9%), unaffordability of services (108; 45.8%) and difficulty in communicating with health workers (85; 36.0%). Post-intervention, utilization improved across all services while the perception of barriers to utilization of services reduced (p < 0.05). The interventions implemented increased the odds of youths utilizing YFHS 1.81 times (95% CI = 1.39–2.37). Conclusion Facility modifications, capacity building of health workers, school and community outreaches, peer group activities, and interpersonal communication improved utilization across all services while the perception of barriers to utilization of services reduced. Implementation of YFHS is impacted by external factors often beyond the control of project implementers. Innovative solutions outside of routine health care delivery systems are critical for success. Further evaluation to explore the effect of these interventions is needed. Strengthening of health systems remains a vital strategy for scale-up of YFHS.