Are facility service delivery models meeting the sexual and reproductive health needs of adolescents in Sub-Saharan Africa? A qualitative evidence synthesis.

Three distinct facility-based adolescent-friendly SRH delivery models are used in Sub-Saharan Africa: Stand-alone clinics, Youth-friendly corners, and Integrated/mainstreamed models.

• The review identified these three models through a systematic search of 14,415 articles, of which 20 papers met inclusion criteria.
• Stand-alone clinics operate as dedicated facilities exclusively for adolescents.
• Youth-friendly corners are designated spaces within existing health facilities.
• Integrated/mainstreamed models incorporate adolescent SRH services within general health services.
• Databases searched included Web of Science, MEDLINE, Scopus, PubMed, and Google Scholar, with PRISMA guidelines followed.

Adolescents in Sub-Saharan Africa expressed the need for comprehensive SRH information, adolescent-friendly facilities, parental and male involvement, and respectful healthcare providers.

• These needs were identified through thematic synthesis across the 20 included qualitative studies.
• Adolescents specifically identified respectful and non-judgmental healthcare providers as a key need.
• The need for parental and male partner involvement was highlighted as important to adolescent SRH service uptake.
• Adolescents desired facilities that were physically and socially accessible and welcoming to their age group.

Adolescent-friendly interventions, friendly staff, and accessibility were identified as facilitators that promote positive SRH service experiences among adolescents.

• These facilitators were reported consistently across studies included in the qualitative evidence synthesis.
• Friendly and non-judgmental staff were a key driver of adolescents' willingness to seek and return for SRH services.
• Physical and geographic accessibility of facilities was reported as promoting service uptake.
• Community-based interventions were identified as complementary facilitators to facility-based models.

Negative attitudes of health workers were identified as a major barrier to effective SRH service delivery for adolescents in Sub-Saharan Africa.

• Healthcare provider negative attitudes and behaviours were among the most consistently reported barriers across the 20 included studies.
• Providers' judgmental or stigmatizing behavior discouraged adolescents from seeking SRH services.
• This barrier was present across all three facility-based delivery models identified in the review.
• The review calls for enhanced provider training to address this gap.

Lack of confidentiality and privacy was a significant barrier limiting adolescents' use of facility-based SRH services.

• Concerns about confidentiality were reported across multiple studies in the synthesis.
• Adolescents feared that their personal health information could be disclosed to parents, community members, or others.
• Intimidating environments within health facilities also contributed to adolescents avoiding services.
• The review recommends strengthening confidentiality assurances as a priority intervention.

Financial constraints and transportation challenges were structural barriers preventing adolescents from accessing facility-based SRH services.

• These barriers were identified alongside negative provider attitudes and lack of confidentiality as key limiting factors.
• Financial constraints were compounded by broader contextual factors including poverty and illiteracy noted in the study population.
• Transportation challenges particularly affected adolescents in rural or remote areas of Sub-Saharan Africa.
• The review recommends reducing financial barriers and expanding out-of-facility services to address these structural issues.

Waiting time and intimidating environments at health facilities were additional barriers discouraging adolescent use of SRH services.

• Long waiting times were reported as a deterrent to adolescents seeking SRH care at facilities.
• Intimidating clinical environments made adolescents feel unwelcome or fearful.
• These barriers were identified through thematic analysis using Thomas and Harden's approach managed with NVIVO 12 PRO software.
• These factors contributed to the overall finding that current facility models do not fully meet adolescent SRH needs.

The review recommends expanding out-of-facility services and adopting mHealth solutions to complement facility-based SRH delivery models for adolescents.

• mHealth solutions were identified as a promising approach to reaching adolescents who face barriers to facility-based care.
• Community-based interventions were found to be important complements to facility-based models.
• The recommendation for out-of-facility expansion was driven by findings that current models leave significant gaps in service delivery.
• These recommendations were framed as necessary to ensure equitable and effective access to SRH services for adolescents across Sub-Saharan Africa.