Young people’s experiences in accessing sexual and reproductive health services in sub-Saharan Africa from 1994 to 2019 - A content analysis

Two and a half decades after the International Conference on Population and Development in 1994, access to Sexual and Reproductive Health (SRH) services by young people is very low, particularly in sub-Saharan Africa (SSA) despite the increasing resources being targeted at addressing the SRH needs of young people. This paper focuses on the needs and experiences of young people in accessing SRH services in SSA. Using a content analysis tool, this paper focused on review of published articles on barriers to SRH services, access and utilisation among young people in SSA from 1994 to 2019. Guided by the focus of the analysis, 21 studies out of 257 were finally selected, and findings presented from Burkina Faso, Ethiopia, Ghana, Kenya, Mali, Nigeria, South Africa, Tanzania, Uganda, Zambia, Democratic Republic of Congo and Zimbabwe. We found that unfriendly remarks by health providers; feeling embarrassed, shame and fear; limited information on SRH services; misconceptions about SRH services; lack of confidentiality and privacy are the major barriers to young people accessing SRH services. Addressing the negative attitude of health providers and the general misconceptions on SRH services are critical to improving SRH service utilisation among young people in SSA.

Introduction

In 2014, it was estimated that half of the world’s population was under 25 years old and the young people under the age of 25 years constituted 1.8 billion [1,2]. Due to high fertility rates, the proportion of young people is far greater for the developing regions especially, sub-Saharan Africa (SSA) [3]. Young people continue to suffer greater risks of Sexually Transmitted Infections (STI), Human Immunodeficiency Virus (HIV) and unintended pregnancies. For instance, one-half of all people currently infected with HIV are females less than 25 years [4–6]. Since the International Conference on Population and Development (ICPD) drew attention to the special needs of young people regarding their sexual and reproductive health in 1994 [7], many programmes, activities and research studies have been carried out to address their sexual and reproductive health needs. Yet after two decades of the ICPD, the adoption of services by the young people is very low, particularly among those in SSA. This is because there are many challenges that prevents young people from wanting to use SRH services even when they are available. A common misconception that the young people should not be sexual beings and the general stigma around their sexuality makes it difficult for them to gain the needed information and SRH services. Young people may be too embarrassed to talk about sexuality with parents and experience communication difficulties with their sexual partner, leaving them unable to articulate their reproductive desires [8-12]. This is particularly true for girls, who are also subject to norms governing gender-appropriate expression of sexual needs and desires. Young people especially girls report experiencing fear, shame and embarrassment because of the stigma they encounter in seeking family planning information and services and using contraceptives [13].

Specifically, in many sub-Saharan countries, condoms are often associated with promiscuity, making girls reluctant to use them as male partners might view them as having “loose morals” [13,14]. For young men, condom use may also be stigmatized, given its association with a lack of masculinity, distrust of partner, or carrying a disease, resulting in boys being reluctant to use them [15–17]. Also, the belief that condom decreases sexual pleasure, the lack of knowledge of how to use condoms, or fear of rejection by a partner discourages young men from using condoms [18,19]. However, the benefits of promoting the SRH of young people are far-reaching. For example, positive interventions can reduce the likelihood of teenage pregnancy and its social and economic costs. Delaying marriage and parenthood can allow for greater educational achievements and thus improve career and employment opportunities. The prevention and treatment of STI and HIV and AIDS also reduce social stigma and help young people remain healthy, enabling them to better care for and invest in their families, communities and countries.

Several studies have looked at SRH service utilization, youth service preferences, and important factors for young people when seeking SRH services [20–22]. Most of the studies have not defined the barriers to successfully obtain the services. Senderowitz described four categories of reasons why adolescents avoid using SRH services: (i) policy constraints, (ii) operational barriers (hours of operation, transportation, cost), (iii) lack of information, and (iv) feelings of discomfort (belief that services are not for them, concern over hostile staff, fear of medical procedures among others [23,24]. This gives a comprehensive categorization of the problems, but to the best of our knowledge, there is no publication presenting a content analysis of studies of barriers affecting young people’s access to and use of SRH services in the sub-Saharan African region. Identifying the barriers to young people’s up-take of sexual and reproductive health services is critical to realising the demographic dividend and placing young people at the centre of the post-2015 agenda for sustainable development in the region. This review is therefore urgent and timely and focuses on empirical studies published between 1994 and 2019 on young people’s experiences in accessing SRH.

Methods

Data search

A search of the following electronic databases was conducted: PubMed, Google Scholar, CINAHL, PsychINFO, Popline, and JSTOR to identify studies in which the primary focus was on factors affecting young people’s access to, use and perceptions of SRH services in sub-Saharan Africa. Since issues relating to SRH became more prominent following the ICPD in 1994 [7] and the Millennium Development Goal (MDG) 5b aimed to achieve by 2015, universal access to reproductive health, each database was searched for articles published in English between 1994 and 2019 using a combination of the following keywords: young people, young persons, young women, young men, youth, teen, adolescent, sexual health service, reproductive health service, contraceptive service, STI services, unsafe sex, and youth friendly services among others. The lists of references in the retrieved documents were also examined with a view to identifying additional publications of interest. Two hundred and fifty-seven articles and reports were obtained (Figure 1). The literature review was guided by this question: What are the barriers young people experience when accessing SRH services?

Figure 1: Flowchart of included and excluded studies.

Exclusion and inclusion criteria

The search was limited to studies from sub-Saharan Africa due to cultural variations with other regions of the world. This brought the number down from 257 to 87 articles and reports for further exploration. Subsequently, studies focusing primarily on SRH service type utilization or preferences, facilitators of SRH service utilization, intervention studies, reviews and reports were excluded. Also, articles that focused solely on the health providers’ or parents’ perspectives on SRH service but did not include those of the young people were excluded. This brought the number of papers down to 21 articles which fulfilled the inclusion criteria of being: (i) based on empirical research; (ii) focused on 10 to 24-year-olds; (iii) focused on at least one barrier category and (iv) having a minimum sample size of 200 survey for the quantitative studies, and qualitative studies also having young people’s voices represented. The 21 studies that were finally selected presented findings from Burkina Faso, Ethiopia, Ghana, Kenya, Mali, Nigeria, South Africa, Tanzania, Uganda, Zambia, Democratic Republic of Congo and Zimbabwe. Three studies were done in multiple countries (Table 1).

Data analysis

This review included both qualitative and quantitative studies. There is a growing number of review articles combining both qualitative and quantitative data to synthesise evidence [25,26]. Content analysis explores text [27]. The text used for this analysis was the written material from the results of the selected studies. The reason for selecting this method was to provide a structure by classifying the experiences, expectations, opinions or views and perceptions of barriers to SRH service presented in the selected studies. This is because content analysis creates new knowledge by drawing important information from the data and structuring it (27). This review used the inductive approach because no theory was not adopted or adapted to guide the data analysis process. This means that the categories were derived from the data [28].

The first step of the inductive data analysis consisted identifying the results from each study relating to experiences, expectations, opinions or views and perceptions of barriers to SRH services which eventually formed the sub-categories (Table 2). This created various codes about the experiences, expectations, opinions or views and perceptions of barriers to SRH service, which were developed into a coding scheme, and involved reading and rereading the articles while coding the data [29,30]. The next step was to find the commonalities between these sub-categories, which, after careful consideration, yielded three major categories; service-accessibility, service-utilization, and service-quality which formed a structure of barriers experienced by young people as shown in the conceptual framework, Figure 2, and were defined as follows:

Figure 2: Conceptual frame of barriers to young peoples’ access to SRH service. Source: Authors’ construct from selected studies

Service-accessibility relates to barriers experienced by young people that stop or do not encourage them to access the SRH services they need. They included: distance to SRH service, feeling embarrassed, ashamed or fear, inconvenient location, difficulty locating SRH service, frequently closed SRH service facility, inconvenient hours of operation, age limitation, gender limitation, not aware of where to go for SRH service, high cost of SRH service, parental disapproval, young person’s disapproval and young person partner’s disapproval as well as misconceptions about contraceptives which also include the following: contraceptives cause infertility, condoms get stuck in vagina, condoms break, contraceptive causes missing of menstrual periods, excessive bleeding during menstrual periods, and no or less pleasure from condom use,

Service-utilization also involves barriers young people encounter from the time they enter the SRH facility till they exit. They included: lack of confidentiality or privacy, fear of being seen by others, long waiting time, uncomfortable waiting room, and adult clients unwilling to talk to young people, and

Service-quality comprise perceptions of barriers from young people’s perspective and included: abusive, discouraging remarks by health provider, discrimination against the unmarried, no attention from health provider, not allowed to express oneself enough, no direction to SRH service area, refused SRH service, not provided with enough SRH information, and service delivery by older or adult health provider.

Results

Selected studies

From Table 1, eight of the selected studies used quantitative methods [11,31–37] whilst another eight used qualitative methods [37-44]. The remaining five studies combined both quantitative and qualitative methods [45-48]. Eight of the studies had their participants from clinics, five used participants from households [11,31,33], three recruited participants from both currently in school and out of school adolescents [38,39,47], and two used only participants in school [32,34]. One study recruited only participants from out of school [41]. Two studies combined multiple settings [45,49] [45,46,49]. One combined school and community [45] and the other combined clinic and households [49]. Also, two articles focused on only females [40,42] whilst one focused on only male [38] and the remaining eighteen considered both gender. In addition, eleven of the studies focused on barriers to SRH services [32,36–40,42,44,46,48,50], three on SRH education [33,34,38]; another three on acceptance of SRH services [43,47,51], two on SRH services preferences [11,31], and one each on satisfaction from SRH services [35] and SRH services utilization [41].

Service accessibility

According to the studies by [31,32,38,41,47,49,52], young people feeling embarrassed, ashamed or afraid was the most reported barrier to accessing SRH services (Table 2). This emotion was usually as a result of the attitude of some health service providers as reported under service quality [49]. using mystery clients (trained people who visit programme facilities in the assumed role of clients) in Senegal reported that the mystery clients said their first contact with the clinics was negative. Some felt afraid, embarrassed, or disappointed as shown in the following illustration: “I was afraid because they [SRH service providers] took me each time to a different person,” and “I was very disappointed because I expected a much friendlier welcome [49].” Furthermore, from some of the selected studies, the young people reported that they were not aware of where to go for SRH service [11,31,38,47]. This was particularly true for studies from the rural settings. Again, some of the selected studies reported that young people found the operation hours of SRH services inconvenient since they were usually in school during those hours [11,35,44]. Others found the location inconvenient because they might be seen by parents or guardians who disapprove of their use of SRH services or they might be seen by their peers who might mock at them [49]. In addition, some of the studies reported that cost was sometimes mentioned as an important barrier to obtaining SRH services [31,32,35,43,44].

Another barrier experienced by the young people was parental disapproval to SRH services especially, the use of contraceptives [34,38,40,43,47]. The quantitative studies reported significant associations between parental approval and contraceptive use [34,40]. Some of the selected studies reported that young people themselves disapproved SRH services for personal or religious reasons [34,41,47,49] or their partner disapproved it for the same reasons. Several studies reported that young women fear that contraceptive use would make it difficult for them to conceive when they eventually get married [39–41,43,53]. Other misconceptions about condoms that hinder young people’s access to SRH services that were reported by the studies were that condoms give less pleasure [39,42,45] or frequently break [38,39,45] or get stuck in vagina [38]. Some studies also reported that missing menstrual periods [32,39] and excessive bleeding during menstrual periods were worrying and therefore, served as barriers to SRH services by young women. Other issues that were also worrying to young people were restrictions to SRH services such as limiting service to only married persons [43,47,49,51] and for persons older than 18 years [51]. This finding is illustrated by the study in Ghana [38], where one boy in a focus group discussion (FGD) for out-of-school participants in urban Ghana said: “Sometimes when you go, they look at your features and they feel that you are not of age. They ask a lot of questions, like; “Who sent you?’’ You are too small.” This is what they say and they send you away [38].” The reviewed studies reported that men complained a lot that the SRH services were oriented to women and only married couples [42,47,49,51].

Service utilization

From the selected studies, young people viewed lack of confidentiality as the most important barrier that hinder their utilization of SRH services [31,35,38,47,48,51,53] as shown in (Table 2). Young people who went to smaller health facilities experienced this more often. In one of the studies [51], half of the young people who participated believed that the health facility staff (i.e. cashiers, receptionists, and medical clerks) could not be trusted to maintain their confidentiality. One boy summed up the common feeling in FGD among in-school participants in Ghana as follow: Like me, if I go to the service and I am looking for a condom, they inform my mother [all participants agree with ‘hmm’]. But I came there for these reasons and then my mother will do something to me, so I feel shy, I am afraid to go, and rather contact my friends” [38]. Another barrier that was of great concern to young people was lack of privacy [35,36,38,48,51,53]. Young people usually reported this barrier together with lack of confidentiality.

The reviewed studies reported that the fear of being seen by parents or other familiar young people is worrying to the young people [32,37,43,51] and this served as a major barrier for SRH service utilization. Investigators in one of the study [43], reported that 72% of the young people reported that fear of being seen by parents or people whom they know hinder their utilization of SRH services. Also, studies reported that long waiting time affected SRH services utilization negatively [31,43,48]. Long waiting time tend to exacerbate the feeling of embarrassment, shame and fear that deter young people from accessing SRH services. In addition, one selected study reported that young men stated that they did not feel comfortable sitting in the waiting area, “between women” [43]. Again, one study reported that young adults often felt that other adult clients in the clinics were biased against them as illustrated by the following quote: “clients don’t want to talk with us young people, since they think we are too young for that” [49].

Service quality

From the reviewed studies (Table 2), attitude of SRH service providers dominated all the barriers reported by young people [11,31,35,38,40,43,47,49,51]. Young people reported several abusive and discouraging remarks from service providers. In one of the studies that the investigators used mystery clients, service providers sent young people away and told them: “go to the pharmacy” or “you would do better to focus on your studies” (49). The included studies reported that young people spoke of being scolded by nurses for many things, such as if they had got previous doses of contraception from a private health service provider, or had used a fixed clinic when their home was serviced by a mobile clinic, or for not arriving at the clinic early in the morning despite the fact that, for most, visiting the clinic was only feasible after school hours [40].

Furthermore, the selected studies reported that the young people complained that the SRH information provided them was at best scanty [38,40,48,49,52]. Though, they reported that pharmacies and chemical shops provided much more compared to clinics or hospitals. Findings from one of the studies showed that majority of boys (in and out-of-school) felt that both public and private health care staff do not provide sufficient information to the youth about contraceptive use and prevention of sexually transmitted infections [38]. Also, according to the studies included in this review, young people did not use SRH services because they felt service providers discriminated against them since they were not married [38,43,47,49].

In addition, the selected studies reported that the young people especially girls stressed the need to be allowed to express themselves enough [35,48,49,52]. Girls described how “simple” things really mattered to them such as: health service provider’s reception and facial expressions, greetings and being given the chance to express themselves and explain their problems. Other barriers that did not enhance SRH services patronage by young people were: no clear direction to SRH service area [48,49], young people being refused SRH services [47,49] and health service providers being older or adult [38,48].

Trends of barriers to young peoples’ access to SRH services

Figure 3 shows the trends observed for the barriers (i.e. Service accessibility, Misconception about contraceptive use Service utilization and Service quality as reported in Table 2) to young peoples’ access to SRH services in SSA over the 25-year period which was categorised into five-year groups (i.e. 1994-1999, 2000-2004, 2005-2009, 2010-2014, 2015-2019).

Figure 3: Trends of barriers to young peoples’ access to SRH services from 1994 – 2019. Source: Authors’ analysis of selected studies.

Generally, a downward trend is observed for all the reported barriers from 2010-2014 to 2015-2019 period. An upward trend is observed for barriers to service accessibility from the beginning 1994-1999 to 2010-2014 where it peaks. Barriers to service utilization also saw an upward trend till it peaks at 2010-2014, albeit, at a lower level compared to that for service accessibility. In the case of reported barriers to service quality, it remained stable from the beginning, 1994-1999 to 2000-2004 period, but drops slightly between 2000-2004 to 2005-2009 period, and a jump is observed between 2005-2009 and 2010-2014 where it also peaks. However, reported misconceptions about contraceptive use by young people generally saw a downward trend over the 25-year period under review.

Discussion

The review brought out three major categories of barriers that deter young people from SRH services patronage: barriers of service-accessibility that discourage or prevent them from accessing SRH services; barriers of service-utilization that young people experience from the time they entered the SRH services facility till they exit and that of service-quality which are encountered at the time of receiving service.

Health service provider attitude stood out as the most important barrier to young people’s access to SRH services. Health care providers’ attitude can either facilitate the use of services or constitute a barrier to the young people seeking SRH services [54,55]. Some SRH service providers were not sympathetic or were less sympathetic to young people who presented SRH cases at their facilities. This included turning away young people who came to ask about services, especially those seeking abortion and STI services as well as dictating the type and nature of services young people should have. The review revealed that young people complained that discouraging and sometimes abusive remarks from health service providers were a great source of worry and a major barrier to them seeking SRH services in sub-Saharan Africa and across the world [37,54-58].

Negative attitude of health service providers was responsible for the embarrassment, fear and shame that the young people experienced which made it difficult for them to seek SRH services [36,59-61,61-63]. Misconceptions about contraceptive methods such as, the use of hormonal methods like the pill and injectable cause infertility were found in the various studies to be major deterrent to some young women from seeking SRH services. These findings imply that education regarding hormonal contraceptives and messaging or social marketing of these services requires renewed attention.

Other studies in sub-Saharan Africa and South America have reported similar findings where contraceptive use by young girls was not approved by young people, community members and health service providers because it was considered to affect fertility of young girls [52,64,65]. However, the trend analysis for the barriers showed that reported misconceptions about contraceptive use by young people generally saw a downward trend over the 25-year period under review. This suggests that SRH programmes, activities and research over the period has made some significant impact in this regard.

Confidentiality and privacy also came out strongly in this review as another worrying barrier to young people’s access to SRH services. This again, could be linked to bad attitude of health service staff. Young people may be particularly reluctant to seek services where breach of confidentiality and privacy exist or are perceived to exist. A recent systematic review of contraceptive service delivery for young people in the UK showed that the most significant concerns for young people were anonymity and confidentiality [60]. In another recent study in UK, a young woman aged 19 years had the experience of her GP sharing something she had told the GP during consultation with her aunt with whom the young woman was currently residing [66]. Yet another concern highlighted by this review that is traceable to the attitude of health service professionals is the provision of inadequate SRH services information or sometimes complete refusal. A similar observation was made in in-depth interviews with young people where the attitudes of health providers in respecting young people as individuals, ensuring confidentiality and meeting their needs for information and services emerged as important considerations for young people who either sought or contemplated seeking health care [67,68].

Conclusion

The review identified significant findings in relation to issues regarding the barriers to SRH services by young people. It has been shown that most of the challenges impeding SRH services’ adoption could be connected to the negative attitude of health service providers as well as misconceptions about SRH services on the part of the young people. There is therefore, the need to intensify training of providers on youth friendly SRH services as well as intensify education of the young people on SRH services to improve acceptance. Based on the findings, the following recommendations are made:

Implications for practice

Training of providers in interpersonal communication, youth counselling skills, youth friendly services should be intensified. Training should also focus on making providers realize that young people may be sexually active or not, married or single and HIV positive or not.

Training curriculum should focus more on making service providers to understand what makes young people seek services, but more importantly, what prevents them from coming and the need for SRH service providers to adapt to the needs of young people, particularly their preventive health needs.

Providers need an understanding of the diversity of young people, their level of knowledge, and their perception of need to be able to serve them appropriately.

In addition, health service providers should be mindful of the fact that not all young people accessing health services are literate, confident, know exactly what to expect, or are capable of explaining what they need or want.

Managers of health services in the region should be proactive in advocating for changes in policies and laws that restrict access to SRH services for young people.

SRH education for young people also ought to be pursued by governments and other stakeholders in SRH services to achieve the needed success as far as adoption of SRH services and post-2015 agenda of sustainable development in the region is concerned.

Implications for research

Future studies should aim to establish whether SRH service-accessibility better predict non-use of SRH services by the young people compared to service-utilization or service-quality. Such understanding is needed to know to what extent the identified barriers deter young people from seeking SRH services. Similar review could be done in the future to know how the identified barriers to SRH services compare with other developing regions of the world.

The lead author would like to acknowledge the capacity building experienced from the Faculty, visiting scholars and colleagues at the Regional Institute for Population Studies (RIPS) and the University of Ghana, Legon, Accra in general. He would also like to recognise the funding and other support he received from the Director, Management, Training Committee and personnel of the Kintampo Health Research Centre (KHRC) as a whole.

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