Ninsiima 

et al. Reprod Health (2021) 18:135

https://doi.org/10.1186/s12978-021-01183-y

REVIEW Open Access

Factors influencing access to and utilisation

of youth‑friendly sexual and reproductive health
services in sub‑Saharan Africa: a systematic
review
Lesley Rose Ninsiima1,3*  , Isabel Kazanga Chiumia1 and Rawlance Ndejjo2 

Abstract 
Background:  Despite the global agreements on adolescents’ sexual and reproductive health and rights, access to
and utilisation of these services among the youth/adolescents remain unsatisfactory in low- and middle-income
countries which are a significant barrier to progress in this area. This review established factors influencing access and
utilisation of youth-friendly sexual and reproductive health services (YFSRHS) among the youth in sub-Saharan Africa
to inform programmatic interventions.
Methodology:  A systematic review of studies published between January 2009 and April 2019 using PubMed, Web
of Science, EMBASE, Medline, and Cochrane Library, and Google Scholar databases was conducted. Studies were
screened based on the inclusion criteria of barriers and facilitators of implementation of YFSRHS, existing national
policies on provision of YFSRHS, and youth’s perspectives on these services.
Findings:  A total of 23,400 studies were identified through database search and additional 5 studies from other
sources. After the full-text screening, 20 studies from 7 countries met the inclusion criteria and were included in the
final review. Structural barriers were the negative attitude of health workers and their being unskilled and individual
barriers included lack of knowledge among youth regarding YFSRHS. Facilitators of utilisation of the services were
mostly structural in nature which included community outreaches, health education, and policy recommendations
to improve implementation of the quality of health services and clinics for adolescents/youth to fit their needs and
preferences.
Conclusion:  Stakeholder interventions focusing on implementing YFSRHS should aim at intensive training of health
workers and put in place quality implementation standard guidelines in clinics to offer services according to youth’s
needs and preferences. In addition, educating the youth through community outreaches and health education pro-
grams for those in schools can facilitate utilisation and scale up of the service.

*Correspondence: [email protected]
1
Department of Health Systems and Policy, College of Medicine, The
University of Malawi, Blantyre, Malawi
Full list of author information is available at the end of the article

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Ninsiima et al. Reprod Health (2021) 18:135 Page 2 of 17

Plain language summary 

Access and utilisation of Youth-friendly sexual and reproductive health is still a big challenge for the youth especially
in sub-Saharan Africa. In this study, we explored the underlying reasons for the low access and utilisation of youth-
friendly sexual and reproductive health services and potential solutions to the problem.
Articles used in this study were retrieved from different data sources and those that contained barriers and facilitators
of access and utilisation of youth-friendly sexual and reproductive health services implementation were summarised.
The key barriers were negative attitude of health workers and their being unskilled emanating from the administrative
section theme. The individual factor was the lack of knowledge among youth. The promoters of utilisation were com-
munity outreaches, health education and improvement of the quality of services in the clinics for adolescents/ young
people’s needs.
Moving forward, stakeholders should aim at increasing the training of health workers and improving the quality of
services being offered to the youth. To address the individual barriers, youth should be reached with information
through community outreaches and education in schools.
Keywords:  Adolescents, Barriers, Facilitators, Reproductive health, Youth, Africa

Background In sub-Saharan Africa, adolescents face many sig-

In many African countries, sexual and reproductive nificant SRH challenges such as limited access to youth-
health (SRH) needs of young people / youth are often friendly services (YFS) including information on growth,
underserved and underestimated despite their dem- unsafe abortion, gender-based violence, sexuality, and
onstrated need and the urgency of these services [1]. family planning (FP). This has led youth into risky sex-
Continental population remain high at approximately ual behaviour resulting in high STI and HIV prevalence
1.2 billion with the highest number being youth aged among young people, early pregnancy, and vulnerability
15–24 years, 226 million—19% of the global youth pop- to delivery complications resulting in high rates of death
ulation—of whom live in sub-Saharan Africa [2]. The and disability [6]. Numerous surveys in LMICs indicated
term young people which according to the World Health that only 33% of young men and 20% of young women
Organisation (WHO) are persons aged between 10 have comprehensive knowledge of HIV but still less than
and 24  years and youth (15–24  years) are interchange- half of young men and women surveyed reported using
ably used but often meaning the youth, adolescents, condoms at their last time of sexual activity [8]. Accord-
and young people [3]. Youth is characterized as a period ing to the 2016 gaps report by UNAIDS, only 10% of
of optimum health with a series of physiological, psy- young men and 15% of young women were aware of their
chological, and social changes that may expose them to HIV status which leaves a big challenge to achieving good
unhealthy explorative sexual behaviour such as early sex reproductive health and wellbeing for all [2]. Young girls
engagement, unsafe sex and numerous sexual partners less than 19 years who get pregnant have a 50% increased
and represent 25% of the world population [4, 5]. risk of stillbirths and neonatal deaths, as well as an
SRH comprises a major component of the global bur- increased risk for preterm birth, low birth weight, and
den of sexual ill-health. Nearly a quarter of girls aged asphyxia which in turn affect the health of the unborn
15–19  years are married with an estimated 16 million child and perpetuate the cycle of poverty [5].
adolescents giving birth each year globally, 95% of whom Youth-friendly services are an amalgamation of health
are from low- and middle-income countries (LMICs) [6]. facility characteristics, health service provision tech-
Trends in delayed marriages do not indicate a decrease niques, and health services offered which are key strat-
in the age of onset of sexual activity among the young egies for improving the health of adolescents in Africa.
people but rather highlights the need to improve access According to the WHO guidelines, in order to be con-
to SRH information, skills and improve services to learn sidered Youth Friendly Health Services (YFHS), the ser-
more about sexuality and prevent unwanted pregnancies vices are required to be accessible, acceptable, equitable,
and sexually transmitted infections [7]. Several factors appropriate and effective, gender-equitable and serve as
are contributing to high adolescent/youth fertility rates a channel for access to FP and SRH [9]. In 2015, WHO/
in sub Saharan Africa, including lack of SRH knowledge, UNAIDS published the Global standards to improve
limited access to/use of contraceptives, condoms, and quality of health-care services for adolescents and ever
SRHS, gender inequality and cultural practices such as since then, many countries have adopted and adapted
child marriage and initiation ceremonies [8]. the Global Standards. Although there has been the
 Ninsiima et al. Reprod Health (2021) 18:135 Page 3 of 17

momentum of implementing SRH services, there are Exclusion criteria

major gaps among the youth in receiving information, Studies or evaluations carried outside sub-Saharan
the effectiveness of the YFS and skills that are affected by Africa, multiple publications, systematic reviews or nar-
culture, and governmental and financial policies [10, 11]. rative reviews, letters to the editor, case reports were
Youth Friendly Services are a key strategy for improv- excluded from the review. Articles written in other lan-
ing young people’s health, however, there is an increas- guages than English were also excluded. Studies with
ing need to break down the barriers to implementation of participants predominately greater than 24 or less than
Youth Friendly Sexual and Reproductive Health Services 10  years of age or with unclear ages were excluded.
(YFSRHS) that prevent the young people from access- Some studies used non-youth key informants and hence
ing quality SRH services in sub Saharan Africa [12]. This excluded.
study thus aimed at reviewing articles on factors influ-
encing access to and utilisation of YFSRHS in sub-Saha- Screening
ran Africa. Title and abstract screening of all papers identified by the
search strategy were independently performed by two
researchers with reference to the published inclusion/
Methods exclusion criteria. Key themes were compiled for each
Protocol article and these themes were grouped based on com-
The protocol for this systematic review was developed mon traits for thematic synthesis, the result section of
following the Preferred Reporting Items for System- each article was analysed using line by line coding. Each
atic Reviews and Meta-Analysis Protocols (PRISMA-P) category was designated a colour code blue for included
guidelines for reporting systematic reviews (Additional and red for excluded. Initial screening of abstracts and
file 1) [13]. The protocol of this review was registered on titles was done using a process of semi automation while
PROSPERO (CRD42020173073). Rayyan QCRI software [14] allowed incorporating a high
level of usability. Reference management software Men-
Data search
deley was used to organise articles retrieved from the
Studies were screened to identify those that examined comprehensive literature review and then analysed.
the availability of YFSRHS and youth perspectives on
these services used to document the barriers to access Quality assessment and appraisal of retrieved
and facilitators of utilisation of YFRHS. The electronic articles
journals and reports were searched comprehensively Quality assessment is crucial to ensure that the findings
by using PubMed, Web of Science, EMBASE, Medline, of the papers are correct and accurate. All studies that
Cochrane Library, and Google Scholar databases. Other meet the eligibility criteria were assessed for quality inde-
sources were identified through scanning of references pendently and in duplicate. The included studies were
of selected sources. All databases were well-established, appraised critically for methodological quality and rig-
multi-disciplinary research platforms, holding a wide our using the Critical Appraisal Skills Programme check-
variety of peer-reviewed journals, and those that will be list (Additional file 2) [15]. We used a modified appraisal
kept up to date (Additional file 2). tool to critically assess the trustworthiness and relevance
of the published papers with a keen focus on the study
design, sampling methods, participant recruitment strat-
Inclusion criteria egy, ethical consideration, data analysis, and findings.
The researchers only included studies that were published
containing articles from sub-Saharan Africa published Data extraction
from January 2009 to April 2019 and had qualitative and/ A common data extraction tool was used for all studies,
or quantitative methods and mixed methods. Qualita- with variation depending on the research design. The
tive research studies included those that employed focus extraction included: what information is to be collected
group discussions, in-depth interviews, and structured on each study (e.g. author, publication source, year), par-
observations. Quantitative research studies of designs ticipants and demographics, study design, outcomes,
were randomized control trials, cross sectional and case– analyses used, and key findings, how the databases or
control. Youth (aged 15–24 years) along with adolescents forms was used, how information was recorded and the
(10–19) years, were included in this review. The review number of reviewers. Two data extractors (NLR and NR)
included studies on youth-friendly service scale-up, uti- resolved the discrepancies and any remaining differences
lisation, and access to YFSRHS and were published in were resolved by the other team member (IKC). As part
English.
Ninsiima et al. Reprod Health (2021) 18:135 Page 4 of 17

of the extraction process, each qualitative and quantita- review. We identified studies focusing on access, utilisa-
tive study was assessed for methodological rigour. The tion and scale-up of A/YFSRHS conducted in sub-Saha-
retrieved data was analysed to answer the main research ran Africa and found articles from 7 countries (Tanzania,
and specific objectives. Nigeria, Ghana, Kenya, Ethiopia, Uganda, and South
Africa) which were included. Nineteen studies used
Synthesis cross-sectional study design, nine selected studies from
Finally, the findings were summarized in a narrative syn- (South Africa, Kenya, Uganda and Ethiopia) used quali-
thesis. The synthesis is presented in the results and dis- tative, six studies from Nigeria and Ethiopia used quan-
cussion chapter. titative methods and the remaining six studies from
Ethiopia, Nigeria, Tanzania and Kenya combined both
Results methods in their studies. Eleven studies had their par-
A total of 23,400 studies were identified through a data- ticipants from the community; four studies were done
base search and an additional five studies from other among both rural and urban communities, one study
sources. After the full-text screening, 20 studies met among urban and peri-urban communities and one study
our inclusion criteria (Fig. 1) and were selected for final in urban communities. In addition, seven studies used

Records identified through database

Additional records identified
searching
through other sources
Identification

(n = 23400)
(n = 5)
18630 PubMed. 4700 Medline, 70 web
of science,

Records after duplicates removed

(n = 18200 )
Screening

Records screened Records excluded

(n = 140 ) (n = 73) due to year published, no
adolescent/youth interventions, no
ASRH/YFSRH scale up
Eligibility

Full-text articles assessed

for eligibility Full-text articles excluded,
(n = 67 )
(n = 45)Based on age criteria,
Population used,
Time period of study was not fitting
other inclusion criteria
Studies included in
No access and utilization focus
synthesis
Included

(n = 22)

Fig. 1  (PRISMA) flow chart: selection process for a systematic review on the access and utilisation of youth friendly sexual and reproductive health
in Sub Saharan Africa
 Ninsiima et al. Reprod Health (2021) 18:135 Page 5 of 17

participants from health facilities and two recruited par- knowledge, individual perception, shame and stigma
ticipants from schools. affecting YFSRHS. Studies evaluating the utilisation
Nineteen articles focused on both males and females level of adolescents/ YFRHS found that only (38.5%)
and one focused on only females (Table 1). adolescents in South Africa and (21.5%) in Ethiopia
were knowledgeable about the type of YFSRH ser-
Study quality vices offered [1, 17]. Youths who lacked knowledge of
The studies presented in (Table  1) had varied methodo- the type of adolescents and YFRHS were not likely to
logical quality. All the studies had clear aims, objectives, utilize the service than their counterparts [5,  19, 20].
and well-justified rationale. The Critical Appraisal Skills High-quality studies assessing knowledge as a bar-
Programme checklist was used to assess for quality of the rier in Nigeria and Ethiopia found that more than two
20 studies. Of these, 14 studies were of high quality, 4 of thirds (79.5%) in Lagos, (98.1%) in Port Harcourt, both
medium quality, and 2 of low quality. All studies defined in Nigeria and (67.3%) in primary health care facili-
their research design [12, 16, 17].  All studies described ties (Ethiopia) of youths did not know of a specific A/
their sample size and participants ‘recruitment strategy, YFRHS provided in their health care facilities [17,
though one study adopted a sampling strategy that was 20–24].
deemed inappropriate in relation to the study aims and Although there YFRHS existed, most adolescents/
objectives [18]. The method used for both quantitative youths were not aware of these services. According to a
and qualitative studies aimed at purposively recruiting medium quality health facility, a cross-sectional study
participants with rich information on the topic of inter- done in Kenya on young people’s perception, knowledge
est. It was also not clear whether biases were considered of younger girls (12–14 years) was limited with a majority
during the design of the study and analysis of the data. reporting that they did not know much about condoms,
The following section synthesizes findings on access and however, boys the same age were more knowledgeable
utilization of YFSRH interventions in sub-Saharan Africa and reported that young people used condoms for pre-
settings by main YFSRH outcome. vention of HIV, pregnancy and other STI [25]. According
to the multivariable analysis on utilisation factors limit-
Barriers to effective access of implementation ing the youths from accessing YFSRHS, in Ethiopia, those
of youth‑friendly sexual and reproductive health services with good knowledge of the type of A/YFSRHS were 1.68
The barriers to access to YFSRHS were categorized as times more likely to utilize A/YFRH service [AOR = 1.68
structural, individual, socio-economic, and socio-cul- (95% C.I.: 1.06–2.65)] [19].
tural. Individual barriers refer to a people having incom- Individual perception, fear, shame and stigma affected
plete or incorrect knowledge of SRH, including myths the utilisation of YFRHS among youth which had a nega-
and misconceptions around contraception; limited self- tive impact among those who believed that YFS can
efficacy and individual agency; constrained ability to nav- improve their health. Youth with stigma and fear about
igate internalized social and gender norms; and lack of YFSRHS were less likely to utilize the service than their
access to information about what SRH services are avail- counterparts in a study carried out in Kenya [12]. How-
able and where to seek services [1] structural barriers ever, in a study from Tanzania, the youth reported that
refer to laws and policies requiring parental or partner adolescents do not seek formal treatment for reproduc-
consent, distance from facilities, costs of services and/or tive health problems as a result of shame and fear of dis-
transportation, long wait times for services, inconvenient closure because of the way they will be looked at by the
hours, lack of necessary commodities at health facilities, community [19].
and lack of privacy and confidentiality [1]. Cultural barri- A study done in Ethiopia found that participants had
ers which refer to as restrictive norms and stigma around the fewest misconceptions about SRH and the most out-
adolescent and youth sexuality; inequitable or harmful standing being misconceptions about oral contraceptive
gender norms; and discrimination and judgment by com- pills causing illness and sterility compared to Rwanda
munities, families, partners, and providers [1]. Social [26]. A study in Malawi also revealed young people’s mis-
economic barriers is general term for pressure that pre- conceptions about contraceptive methods. One study
vents people born into lower class from moving over the participant said “For us youth, there are [contraceptives]
course to receive better SRH like those from affluent class which we can take, and there are others which we cannot
[1]. take as they can bring problems on our lives. The youth
mainly use condoms, that one cannot bring problems
Individual barriers
unlike methods like IUD. People even fall sick because of
The study identified fourteen studies whose pri- such methods.” (Female, in-school, 15–17 years, Mach-
mary aim was to evaluate Individual barriers such as inga) [27].
Table 1  characteristics of included studies exploring barriers to access and facilitators of the utilisation of youth-friendly sexual and reproductive health services among the
youth
Authors name and Country Study settings Study design Aim and objective Approach Age and sex Findings CASP quality
year assessment

Mulaudzi et al. 2018 South Africa Hospital Cross sectional To explore barriers to Focus group discus- Both female and male Barriers; health care High quality
(50) providing adoles- sion and semi struc- providers atti-
Ninsiima et al. Reprod Health

cent friendly sexual tured interviews tude, Counsellors

and reproductive reported inad-
health services equate training to
address adolescent
psychosocial issues,
including adoles-
cents-specific ages
(2021) 18:135

as counsellors
Godia et al. 2014 (47) Kenya Health care facilities Cross sectional Understanding of Focus group discus- 15–24 boys and girls Barriers; in their Medium
and youth centers the SRH problems sion and indepth responses were
young people face interviews broad and reflect
and document the cultural, social
perceptions of avail- and economic envi-
able SRH services as ronment in which
reported by young they live
people themselves. Facilitators; Rec-
explored experi- reational activi-
ences and percep- ties attract the
tions of young boys. Increasing
people awareness through
outreaches
Helamo et al. 2017 (42) Ethiopia Institutions Cross sectional Assesses factors affect- Quantitative 15–24 years female Barriers; Youths with Medium
ing adolescents and male a good knowledge
and youths friendly of the type of A/
reproductive health YFSRHS were more
service utilisation likely to utilize the
among high school service than their
students in Hadiya counterparts, utilisa-
zone, Ethiopia tion levels were low
and youth were una-
ware of the services
being provided
Page 6 of 17
Table 1  (continued)
Authors name and Country Study settings Study design Aim and objective Approach Age and sex Findings CASP quality
year assessment

Ajike et al. 2016 (44) Nigeria Rural and urban Cross sectional The knowledge of Quantitative 15–24 years Barriers; The par- High quality
youths on available boys and girls ticipants knew what
adolescent/youth adolescent/youth
Ninsiima et al. Reprod Health

friendly services friendly services

(A/YFRHS) in Ikeja, were but did not
Lagos State, Nigeria know where to get
these services from
because they were
not aware of the
available A/YFRHS
(2021) 18:135

facilities
Self et al. 2018 (48) Malawi Community Qualitative To explore the per- Focus group discus- 15–24 years female Barriers; to youth High quality
spectives of youth sion and male accessing family
and adults about the planning included
drivers and barriers contraception
to youth accessing misconceptions, the
family planning costs of family plan-
and their ideas to ning services, and
improve services negative attitudes.
Parents had mixed
views on FP,
Atuyambe et al. 2015 Uganda Urban and peri urban Qualitative To assess the sexual Focus group discus- 10–24 years male and Recommenda- High quality
(51) reproductive health sions female tions; establishing
needs of the adoles- adolescent-friendly
cents and explored clinics with standard
their attitudes recommended char-
towards current acteristics (sexuality
services available information, friendly
health providers, a
range of good clini-
cal services such as
post abortion care
Chandra-Mouli et al. Tanzania Urban and rural Survey To extend the reach of Qualitative 15–24 years female Barriers; poor knowl- High quality
2013 (39) Adolescent Friendly and male edge, it had received
Health Services reports that the
(AFHS) in the quality of the AFHS
country being provided by
some organizations
was poor
Recommendations/
policy; standardized
definition of AFS
Page 7 of 17
Table 1  (continued)
Authors name and Country Study settings Study design Aim and objective Approach Age and sex Findings CASP quality
year assessment

Zewdie et al. 2018 (49) Ethiopia In schools Cross sectional Young people’s Focus group discus- 15–24 years female Barriers; poor percep- High quality
perceptions and sion and male tions about SRH,
barriers towards feeling of shame,
Ninsiima et al. Reprod Health

the use of sexual fear of being seen

and reproductive by others, restrictive
health services in cultural norms, lack
Southwest of privacy, in avail-
Ethiopia able services
Rukundo et al. 2015 Uganda Community Cross sectional Views concerning Key informant inter- 15–19 years female Barriers; health work- Medium
(2021) 18:135

(52) factors affecting views and male ers described their

availability, accessi- experience with
bility and utilization teenagers as chal-
of teenager friendly lenging due to their
antenatal services in limited skills when it
Mbarara Municipal- comes to addressing
ity, southwestern adolescent-specific
Uganda needs
Eremutha et al. 2019 Nigeria Rural and urban areas Stratified and pur- To generate increased Mixed method 10–24 female and Facilitators; commu- High quality
(40) posive understanding of male nity mobilization for
the barriers that limit awareness creation
youth access to sex- and support on SRH
ual and reproductive issues will support
health services(SRH) youth to better
offered by access
Primary Health Care Barriers; lack of
(PHC) facilities in awareness, negative
Nigeria attitude of health
workers, cost of
service and parents
perception or fear
Betebebu Mulugeta Ethiopia Facility based Cross sectional To assess youth- Quantitative 15–19 female and Facilitators; comfort High quality
et al. 2019 (53) friendly service qual- male and providers
ity and associated sex, waiting time,
factors at public place of YFS, are
health facilities in factors which are
Arba Minch town, significantly associ-
Southern Ethiopia ated with client
satisfaction in a
health facility
Page 8 of 17
Table 1  (continued)
Authors name and Country Study settings Study design Aim and objective Approach Age and sex Findings CASP quality
year assessment

Ayehu et al. 2016 (43) Ethiopia Community Cross sectional To assess young Quantitative 15–24 years male and Facilitators; Young High quality
people’s sexual and females people from families
reproductive health of higher family
Ninsiima et al. Reprod Health

service utilization expenditure, lived

and its associated with mothers,
factors in Awabel participated in peer
district, Northwest education and lived
Ethiopia near to a Health
Center were more
likely to utilize SRHS
(2021) 18:135

at youth centers
Binu et al. 2018 (6) Ethiopia School based Cross sectional To assess utilisa- Quantitative 10–24 years female Barriers; Inconvenient Low
tion of Sexual and and male times, lack of privacy,
Reproductive Health religion, culture, and
(SRH) services and parent prohibition
its associated factors were barriers to SRH
among secondary service uptake cited
school students by the school youths
in Nekemte town,
Ethiopia
James et al. 2018 (35) South Africa Health facilities Cross sectional To detail the evalua- Qualitative 15–24 years male and Barriers; Facilities Medium
tion of AYFS against female had the essential
defined standards to components for
inform initiatives for general service
strengthening these delivery in place, but
services adolescent specific
service provision
was lacking espe-
cially the sexual and
reproductive health
services
Geary et al. 2014 (41) South Africa Rural health facilities Survey Investigate the Qualitative 12–24 years female Barriers; lack of youth- High quality
proportion of facili- and male friendly training
ties that provided among staff and lack
the Youth Friendly of a dedicated space
Services programme for young people,
and examine health workers atti-
healthcare workers’ tude, did not appear
perceived barriers to uphold the right
to and facilitators to access healthcare
of the provision of independently.
youth friendly health breaches in young
services people’s confiden-
tiality
Page 9 of 17
Table 1  (continued)
Authors name and Country Study settings Study design Aim and objective Approach Age and sex Findings CASP quality
year assessment

Motuma et al. 2016 Ethiopia Community Cross sectional to assess the extent Mixed methods 15–24 years female Barriers; source of High quality
(45) of youth friendly and male information and
service utilization having knowledge
Ninsiima et al. Reprod Health

and the associated about services were

factors among the associated with
youth utilisation, negative
perception about
counselling affected
the outcomes
(2021) 18:135

Renju et al. 2010 (13) Tanzania Health facilities Survey A process evaluation Mixed methods 15–24 years female Barriers; scale up High quality
of the tenfold scale and males faced challenges in
up of an evalu- the selection and
ated youth friendly retention of trained
services intervention health workers and
in Mwanza Region, was limited by vari-
Tanzania, in order to ous contextual fac-
identify key facilitat- tors and structural
ing and inhibitory constraints
factors from both
user and provider
perspectives
Obonyo Perez Akinyi Kenya Community Cross sectional Examined how those Mixed methods 10–24 years female Facilitators; level of Medium
2009 (24) factors determined and male education, type
or affected the of school and
utilization patterns youth’s awareness
of YFRHS by the about existence of
youth. mitigating reproductive health
and addressing chal- facility and services
lenges to scale up offered were sig-
nificantly associated
with utilization
Chimankpam Nigeria Health facility Cross sectional To assess the utiliza- Mixed methods 15–24 years female Barriers; low knowl- High quality
Williams tion of youth and males edge levels
Uzoma 2017 (46) friendly health Facilitators; Friends/
services by young family/contem-
people in Port porary and notice
Harcourt and factors board were major
that affect utilisation sources of informa-
tion
Page 10 of 17
 Ninsiima et al. Reprod Health
(2021) 18:135

Table 1  (continued)
Authors name and Country Study settings Study design Aim and objective Approach Age and sex Findings CASP quality
year assessment
Berhe et al. 2016 (54) Ethiopia Community Cross sectional Assess utilization of Mixed methods 15–29 years females Barriers; negative atti- Medium
youth-friendly ser- and males tude towards youth
vices and associated friendly service
factors in Mekelle utilization
city Facilitator; awareness
and prior knowl-
edge were predic-
tors of utilisation
Numbers in brackets in this table are corresponding number of articles retrieved from the inclusion criteria
Page 11 of 17
Ninsiima et al. Reprod Health (2021) 18:135 Page 12 of 17

Structural barriers where youth clinics exist, participants report a lack of

Eighteen studies in the review indicated structural barri- privacy for SRH services and/or sense of belonging.
ers affecting the delivery of YFSRHS. High-quality studies “When you go to hospitals for services, you may meet
from South Africa and Ethiopia addressed primarily pro- your parents there. I remember my friend who met her
vider attitudes and the clinical environment as barriers mother in a clinic” [34].
to adolescents’ access to healthcare during a focus group
discussion, however, perceptions of provider attitudes Cultural barriers
towards adolescents appeared to be inconsistent [22, Four studies were identified exploring the impact of reli-
28].  During a KI a nurse stated, ‘There are mean nurses gious and traditional beliefs on access to YFSRHS [21,
but there are good nurses [too]… It’s unfortunate that the 23, 26, 34]. Social-cultural factors were greatly associ-
South African public, it’s like every time when they go ated with some services mainly FP, voluntary counselling
to the clinic they meet the mean nurses only. They never and testing, and counselling services. It was established
get to meet the good nurses.’ (Female clinical nurse, SSI that some cultures and parents in a community cross sec-
4) [28]. Negative attitude of health workers as per the tional study done in Kenya and Ethiopia prohibited the
case in one of the studies indicated that 30% had negative youth from utilising YFRHS as this was brought out when
attitudes towards the youth in Ethiopia [15]. From focus a descriptive, chi-square and odds statistics all showed
group discussions (FGDs) in a study done in Uganda, significant relationships [21, 23]. Some participants in a
(18/20) participants indicated that experiencing health study done in Malawi indicated that parents expressed
care provider’s negative attitudes towards providing SRH negative opinions of youth using FP and parents could
services affects the utilisation aspects among adolescents prevent youth from accessing FP services and also said
[29]. Health worker attitudes can also significantly hinder youth below age 18 are not old enough to be sexually
adolescents’ utilisation of Reproductive Health Service active. Therefore, the youth did not need FP and should
(RHS). Services need to be provided in a youth-friendly focus on completing their education and not engage in
environment with health workers that are welcoming and sexual activities [26].
supportive towards adolescents seeking care [30].
At the same time, the number of skilled health work- Socio‑economic barriers
ers to offer these services is limited which was identi- Three studies reported that adolescents and young peo-
fied in a study carried out in South Africa, Ethiopia, and ple mostly preferred low cost or no charges at all when
Uganda [16, 31, 32]. The studies indicated the most com- seeking SRH services from youth centers. A high-quality
mon barriers to providing health services to young peo- study exploring barriers and perspectives of youth seek-
ple, and YFS specifically was related to shortages of staff ing FP services found that in one district participants
with training on the provision of YFRHS and the lack of some government providers charged fees for FP for both
a dedicated space for young people at the facilities [20, male and female youth. The other mentioned barriers
22, 33]. Data collected in Tanzania indicated that 37.2% were transport costs and long distances [26]. Similarly,
of the service providers who were interviewed reported another high-quality study in Uganda [29] and medium
that they had received training in adolescent sexual and quality studies in Kenya [33] and Nigeria [20] also showed
reproductive health (ASRH) information and counselling similar results as in nineteen of the twenty FGDs, ado-
which is significantly very low and had disparities [12]. lescents noted that where the services were not free, the
Counsellors in a study done in South Africa stated that cost was not affordable to them. Two studies in different
they had received limited or no training in counselling states of Ethiopia, most respondents mentioned the chal-
adolescents. While all counsellors had general HIV/AIDS lenge of cost of services (21%) and (41.2%) respectively,
counselling skills, only a few had received formal training lacked money as its needed to travel to health facilities as
in adolescent development [28]. the distance/time taken is costly [23, 24].
Many operational barriers in health facilities also
impact access and utilisation of these services, such as Facilitators to the effective utilisation
inconvenient operating times, lack of transportation, and in the implementation of youth‑friendly sexual
high cost of services [5, 21, 26]. A study in Uganda indi- and reproductive health services
cated that the overall quality of SRH services at the facili- The studies included in this review only reported struc-
ties was of poor quality to most of them as reported in tural facilitators which are described below.
fifteen of twenty FGDs [29]. In a study from Ethiopia, one
of the participants indicated the lack of separate youth Community outreach and involvement
clinics saying, designated space for provision of YFSRHS Five studies reported on community outreach and
has been mentioned numerous times as a barrier. Even involvement in terms of outreach activities in the
 Ninsiima et al. Reprod Health (2021) 18:135 Page 13 of 17

community, schools and churches among the youth/ in this study where peers or friends were found to be
adolescents. However, some indicated lack of informa- the major source of information. Peers were mentioned
tion regarding different areas of YFSRH which was doc- as resources to support other youth if they shared news
umented in the above studies. A medium quality study and information about FP, but they were also reported
done in Ethiopia indicated that (45.9%) had information to sometimes mock and tease others who they knew
about the availability of services in the nearby facility and wanted to use FP [26]. Friends/peers (45.7%) were the
the most important sources of information were peers best sources of information on A/YFRHS, however, the
(54.6%), parents (27.1%), and mass media (7.6%) [19]. The most popular services known were FP (81.6%), volun-
use of local radio stations, posters, magazines, sporting tary counselling and testing (73.8%), and sexually trans-
activities and entertainment were mentioned by majority mitted diseases (67.3%) [21]. The consensus opinion was
of the respondents in the study as a great way to promote that young people who came to the Youth Centre to play
YFSRH [35]. In studies done in Uganda, participants in games or be involved in other activities eventually would
the outof-the school male adolescent FGDs preferred end up using the centre’s SRH services if needed [25].
services such as outreaches in the communities at no cost Both girls and boys noted that games such as the pool
and preferably with health workers not from the same only attracted boys and made girls shy away from com-
area [34]. In Malawi a study on youth perspective on how ing to a youth centre. Also, youth playing games at the
to increase awareness noted that: “outreaches is what same place where health services are provided can be a
will help them [young people] because most of them do promoting factor as it brings people together to discuss
not know about what [service] is at the youth centre the the problems they face and improve them [22, 34].
youth do not know what kind of youth-friendly [services]
are available” (FGD Boys, Meru) [29]. Recommendations/options for improving YFSRHS
In a study done in Ethiopia, mass media messages implementation
(70.9%), advice from others (31.1%), illness of close rela- Improving the characteristics of YFSRHS to favor youth’s
tive (8.6%) and death of close relative 23(9.4%) were the needs and preferences
most important factors that influenced the study partici- Two studies indicated how youth’s needs and preferences
pants to utilize the services [19]. Similarly, results from are to be considered in order to improve YFSRH services.
a study in Nigeria indicated that community mobiliza- In a high-quality study [28], participants expressed the
tion for awareness creation and support on SRH issues need for improvement in A/YFSRHS.
(59.3%), supported youth to better access SRH services in Recommendations on the implementation of health-
Primary Health Care Facilities [17]. care service provision should be characterized by a
prompt, entertaining and welcoming environment that
School health education would encourage adolescents to interact freely. In high-
Four studies reported adolescents and young people quality study [32], health workers viewed a teenager-
mostly preferred in-school health education [5, 16, 32, friendly service as one that could provide privacy and
36] however, some preferred out-school health education sufficient time and patience when dealing with teenag-
as sources of seeking YFSRH services [32]. School health ers. They also described that a friendly service would be
education promoted youth awareness and involvement offered by health workers with specific training in teen-
in access and utilisation of YFRHS as it was indicated in age pregnancy and with knowledge of how to allocate
a high-quality study [36]. Participants described health specific time to teenagers [22]. A study in Nigeria [28]
education and specific space for the teenagers as key indicated that a large percentage (80.0%) of the respond-
components of a teenage friendly service with a signifi- ents believed youth counsellors were best at serving other
cant number from a study done in (81.7%) Nigeria said youth in the community because they are able to relate to
that in-school clubs can create demand for SRH services their health needs better. In a hospital-based cross-sec-
and 64.7% of them also agreed that out-of-school clubs tional study done in South Africa, one of the respondents
are important for SRH services [16, 32]. In a low-quality in an FGD said; ‘Include teenagers in the programmes.
study in Ethiopia, the majority of the respondents (72.7%) I think that would make a major, major difference.’ (P5
who were involved in the available school clubs and female counsellor) during the design and implementation
(54.3%) had discussed on YFSRH issues with friends put of the programmes being delivered [17].
them at high levels of utilisation [5]. In two high-quality studies done both in Uganda [26]
Youths who participated in peer to peer discussions and Malawi [29], the most common suggestion among
were more likely to know about and utilize sexual and youth participants and parents was the need for more
reproductive health services than those who did not par- information on FP through counselling which would
ticipate. Peer influence remains a strong factor as shown ensure youth understand the importance on FP and how
Ninsiima et al. Reprod Health (2021) 18:135 Page 14 of 17

methods work. A medium quality study in South Africa different factors including stigma related to young age,
encouraged training and on-going support to be provided parental consent, access to YFSRH services and com-
to facilitate this; the importance of such training was to modities is challenging because of distance, costs, and
encourage more than one member of staff per facility quality of services. The studies in this review show simi-
to be equipped to allow for staff turnover [1]. In Kenya, lar findings with a systematic review done on SRH knowl-
majority of the respondents wished to see an increase in edge, experiences and access to services among refugee,
SRH services especially in rural areas including the use of migrant and displaced girls and young women in Africa
mobile clinics. which indicated the limited SRH knowledge and aware-
The consensus was that providing a wide range of SRH ness among adolescent girls which cause the adolescents
services in either integrated health facilities or youth cen- to refrain from using them [39].
tres was more likely to ensure anonymity and that pri- Few studies reported on socio-economic and cultural
vacy could be maintained [25]. Meeting these standards barriers due to the fact that some services were not free
could make a major contribution to securing adolescents’ and the youth lacked money. Others findings from this
health, especially in preventing unintended pregnancies study indicate that health workers or fellow peers and
and HIV [18]. parental consent on FP services is not given even when
these services are offered free. Some services are not free
Implementing quality standards for YFSRHS of charge such as FP and the cost of receiving them due
Two high-quality studies assessed another key factor in to distance is costly, so the youth opted-out from using
development and implementation of quality standards them. These barriers are due to the context and structure
found in Tanzania [16] during the scale-up of YFSRHS, of the environment in which the youth live in.
and utilisation of YFRHS in Nigeria [24] and recom- Only two studies were identified focusing on scale-
mend that a useful means of ensuring that efforts to make up of YFS which were from one country (Tanzania) and
health services adolescent friendly are grounded in wider still had scale-up challenges in the selection and reten-
public health initiatives at the national, regional and tion of trained health workers and was limited by vari-
council levels. ous contextual factors and structural constraints which
still pose a barrier to utilisation of YFSRH [16]. In addi-
Discussion tion to research on delivering and scaling up YFSRHS to
This systematic review aimed at synthesizing evidence on different youths, we should also consider implementation
barriers and facilitators affecting access and utilisation research in different sub-Saharan countries like YFSRHS
of YFSRHS together with recommendations to improve being grounded in wider public/global health initiatives
and scale-up these services for youth/adolescents in sub at the national and regional levels in order to play a larger
Saharan Africa. The most common barriers in the review role in implementation and delivery than in static set-
were structural which included the negative attitude of tings where nongovernmental organizations deliver most
health workers, inconvenient hours, quality of services of the services.
and unskilled health workers. The health workers attend- The review indicated that facilitators to the utilisation
ing to the youth were reported to use abusive languages of YFSRHS included community outreaches and involve-
while others were not sympathetic enough to provide ment, school health education, peer-led education and
services like FP and contraceptives. Moreover, some were mass media campaigns, and sporting activities and enter-
not trained adequately/not at all on how to deliver the tainment activities at youth centres which were sources
services to the youth posing a great challenge. A similar of information preferred by the youth and improved
observation was found in a context analysis assessing YFHRS access and all were structural in nature. The
young people’s experience of SRH in sub-Saharan Africa World Health Organization (WHO) review on universal
[37]. access showed that actions to make SRHS user friendly
The review showed the second prominent barrier were and welcoming had led to an increase in the use of ser-
at the individual level emanating from limited access to vices by adolescents [21]. The review suggests that youth
YFSRHS including limited knowledge and awareness are more likely to seek sexual health information from
among adolescent/youth about the services which is a community outreaches and health education in schools
key hindrance. Adolescents have limited and, in some and among peers. The health workers’ attitude and lim-
cases, no access to SRH education and contraception, ited skills should be assessed critically and prioritized
making adolescent girls more prone to early and unin- as adolescents/youth are willing to access these services
tended pregnancies [38]. To summarize, the youth’s lack through them.
of knowledge on YFSRH issues; access to reproductive YFSRHS whether offered in dedicated youth centers
health information is often hindered because of many or public health facilities attract both male and female
 Ninsiima et al. Reprod Health (2021) 18:135 Page 15 of 17

clients around the world. Similar findings to a study of the studies (n=13) selected were graded as high qual-
done in Sweden, which has youth centers throughout the ity, 30% as medium quality (n=6), and 5% as low quality
country, liberal attitudes and few legal barriers to service (n=1). There was limited number of use of stratification,
provision, however, the majority of patient visits to youth by gender and age as some studies indicated the differ-
centers were made by females [40]. ences, and so we were not able to capture potentially
This review identified the need to improve access to differing health access and utilisation outcomes among
and standardise the quality of health services for ado- adolescents/youth.
lescents/youth needs along with integrating efforts such In terms of limitations, the narrow inclusion criteria
as educate, empower and support adolescents. A user- may have led to the exclusion of some peer-reviewed
friendly SRHS does not necessarily ensure service utili- literature and conference articles. Additionally, our lan-
zation by adolescents/youth. Similarly, a review done on guage inclusion criteria, i.e. only studies published in
assessing YFSRHS indicated the need for standardisa- English, imposed by the capacity of the research team
tion and prioritisation of indicators for the evaluation of may have limited the numbers of hits returned by our
YFSRHS which include accessibility, staff characteristics search and led to publication bias. Nevertheless, this
and competency, and confidentiality and privacy favoring review provides important information on barriers and
youth’s needs [2]. During the scale-up of YFSRHS in Tan- facilitators of access and utilisation of YFSRHS imple-
zania, there were gaps in the standardisation of services mentation and proposes key recommendations which
according to Global standards for quality of health-care should inform design and implementation of effective
services for adolescents which is still a major challenge. YFSRHS programmes.
Standardized systems within a country on the use of
data recorded at the health facility level and combined Conclusion
supportive supervision with regular self-assessments to The review has shown that most common barriers
improve the quality of services is a facilitator to utilisa- impeding YFSRH services were due to structural barri-
tion of YFSRHS which has not been found in any articles ers such as the negative attitude of health workers and
reviewed hence a gap. The Global Accelerated Action for unskilled health workers, and individual barriers ema-
the Health of Adolescents (AA-HA!): guidance to support nating from low levels of knowledge among the youth/
country implementation recommends that standards- adolescents. Regarding facilitators of utilisation, results
driven quality improvement should be positioned within showed that with sustained community involvement and
national adolescent health programmes within a specific outreach, school health education, recreational activities,
country [2]. Despite the existence of laws and policies, and the provision of free or reduced-cost YFSRH to those
effective implementation can only be managed through with a financial constraint, there will be an increase in
political commitment, adequate resource allocation, utilisation together giving the youth access to the health
capacity building and the creation of systems of account- services hence promoting sustainability. The Global
ability to cater for effective access and utilisation of guidelines on standardisation of health services encour-
YFSRHS [3]. Evidence shows that focusing on strength- age that adolescent service providers prioritise quality
ening health systems to meet the adolescents’ needs has however, YFSRHS are highly fragmented, poorly coordi-
a positive effect on access and uptake of some YFSRHS nated and uneven in terms of quality. Pockets of excel-
[41]. Further, evidence shows that many health system lent practice exist, but, overall, services need significant
interventions and reforms have led to an increase in cov- improvement and should be brought into conformity
erage of several health services [11]. These gaps point to with existing guidelines. The review emphasizes the need
the need for robust and timely research on the mecha- to educate and health train the youth/adolescent to know
nisms through which YFSRH facilitators can increase uti- more about the reproductive health services being pro-
lisation and access across a variety of sub-Saharan Africa. vided at youth-friendly centers and their involvement in
Further studies should be done on how cultural factors the design and implementation of interventions targeting
such as religion and beliefs affect access and utilisation of them. Stakeholder interventions focusing on implement-
YFSRH services. ing YFSRHS should aim at intensive training of health
Evidence on attribution is particularly weak, with workers and put in place quality implementation stand-
majority of studies using a cross-sectional design, with no ard guidelines in clinics to offer services according to
control group. Qualitative studies have the potential to youth’s needs and preferences.
contribute rich perspectives from study populations on
YFSRH service utilisation and barriers to access, but we
Abbreviations
found only three studies using this design, and six studies A/YFSRHS: Adolescent/youth friendly sexual and reproductive health services;
using mixed methods to assess YFSRH. Overall, only 65% SP: Service providers.
Ninsiima et al. Reprod Health (2021) 18:135 Page 16 of 17

Supplementary Information Nigeria: a mixed methods approach. BMC Health Serv Res. 2018. https://​
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1
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mental Health, School of Public Health, College of Health Sciences, Makerere bel woreda, Northwest Ethiopia. Reprod Health. 2016. https://​doi.​org/​10.​
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and Herbal Medicine, Department of Health Systems and Policy, Global Health 21. Ajike SO. Adolescent/youth utilization of reproductive health services:
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