Advertisement

Sexually Transmitted Infection Services for Adolescents and Youth in Low- and Middle-Income Countries: Perceived and Experienced Barriers to Accessing Care

      Abstract

      Purpose

      Access to sexual and reproductive health (SRH) services is vital for sexually active adolescents; yet, their SRH care needs are often unmet.

      Methods

      We conducted a qualitative systematic review of mixed methods studies to assess adolescent and provider views of barriers to seeking appropriate medical care for sexually transmitted infection (STI) services for adolescents. We searched peer-reviewed literature for studies published between 2001 and 2014 with a study population of youth (aged 10–24 years) and/or health service providers. Nineteen studies were identified for inclusion from 15 countries. Thematic analyses identified key themes across the studies.

      Results

      Findings suggest that youth lacked knowledge about STIs and services. In addition, youth experienced barriers related to service availability and a lack of integration of services. The most reported barriers were related to acceptability of services. Youth reported avoiding services or having confidentiality concerns based on provider demographics and some behaviors. Finally, experiences of shame and stigma were common barriers to seeking care.

      Conclusions

      Adolescents in low- and middle-income countries experience significant barriers in obtaining STI and SRH services. Improving uptake may require efforts to address clinic systems and provider attitudes, including confidentiality issues. Moreover, addressing barriers to STI services may require addressing cultural norms related to adolescent sexuality.

      Keywords

      Implications and Contribution
      This review provides an overview of perceived and experienced barriers for youth seeking sexually transmitted infection services in low- and middle-income countries. The findings identify themes related to persisting barriers to seeking care for sexually transmitted infection services that should be considered when assessing and designing sexual and reproductive health systems and services.
      It has been estimated that there were approximately 489 million new cases of curable sexually transmitted infections (STIs) (e.g., chlamydia, gonorrhea, syphilis, and trichomoniasis) among adolescents and adults (15–49 years) worldwide in 2008 [
      World Health Organziation (WHO)
      Global incidence and prevalence of selected curable sexually transmitted infections – 2008.
      ]. In high-income countries such as the United States, robust disease surveillance systems demonstrate adolescents and young adults are disproportionately affected by STIs [
      Centers for Disease Control and Prevention
      Sexually transmitted disease surveillance 2013.
      ]. Thus, access to sexual and reproductive health (SRH) services is vital for sexually active youth and adolescents. However, research indicates that health services in many countries may not fully address their SRH needs [
      United Nations
      UN interagency task team on HIV and young people. Guidance brief: HIV interventions in the health sector.
      ,
      • Bearinger L.H.
      • Sieving R.E.
      • Ferguson J.
      • et al.
      Global perspectives on the sexual and reproductive health of adolescents: Patterns, prevention, and potential.
      ,
      • Mbizvo M.T.
      • Zaidi S.
      Addressing critical gaps in achieving universal access to sexual and reproductive health (SRH): The case for improving adolescent SRH, preventing unsafe abortion, and enhancing linkages between SRH and HIV interventions.
      ]. This is especially true for STIs and may be heightened in countries with fewer resources dedicated to health care.
      In 2001, the World Health Organization (WHO) organized a global consultation on adolescent-friendly health services. One of 10 consensus statements was, “for a variety of reasons, adolescents are unable and or unwilling to obtain the (general) health services they need” [
      World Health Organziation (WHO)
      Global consultation on adolescent friendly health services: A consensus statement.
      ]. A 2005 review of research through 1999 focused on the need for adequate STI services and identified barriers that adolescents experience in obtaining needed STI services [
      • Dehne K.L.
      • Riedner G.
      Sexually transmitted infections among adolescents : The need for adequate health services.
      ]. Such barriers have been classified into four categories—availability, accessibility, acceptability, and equity [
      World Health Organziation (WHO)
      Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
      ].
      Understanding what the current barriers are globally, and by region, could provide an understanding of what challenges still exist. STI services are often grouped in a larger cadre of SRH services in many settings, and thus, for the purposes of this review we have sought to understand barriers to adolescent access to STI services including the context of SRH services. In addition, it is important to determine whether the barriers that adolescents experience have changed in the new millennia.
      Thus, we conducted a qualitative systematic review of studies with a variety of methods (quantitative, qualitative, and mixed methods) to assess adolescent and provider views about the experienced and perceived barriers for youth seeking appropriate medical care for STI services. Specifically, we sought to answer the following key questions:
      • 1.
        In seeking appropriate care for STIs, what barriers do adolescents experience or perceive in relation to accessing and using STI-related care?
      • 2.
        What are providers' views about adolescent access to SRH care? How do providers feel about providing adolescent SRH care?

      Methods

      We conducted a systematic review of peer-reviewed literature for studies published between 2001 and 2014 (inclusive) with a study population that included adolescents and youth (aged 10–24 years) [
      • Clark S.
      Early marriage and HIV risks in sub-Saharan Africa.
      ], who we will refer to as “youth” throughout, and health service providers (Table 1). Inclusion and exclusion criteria are provided in Table 2. We included studies that (1) focused on youth or providers (i.e., those who provide SRH services to adolescents); (2) focused on barriers experienced by adolescents in accessing SRH care; and (3) included STI services or referenced STI services in the results. Studies that included adolescents as a subpopulation were not included in this review.
      Table 1Search protocols
      Databases
       MEDLINE, Google scholar, PsychInfo, Web of Science, EMBASE, CINAHL,
      Hand searches
       International Perspectives on Sexual and Reproductive Health, Sexually Transmitted Infections, Culture, Health and Sexuality, Journal of Adolescent Health, Lancet
      Search terms
       Adolescent terms
      Adolescent(s), Youth/young people/young adults, teen/teenage, student, juvenile, boy/girl, young men/women
       Health service and access terms
      Sexual, Sexual health, Reproductive health
      Condom, contraception, family planning
      Services, youth friendly services, confidential services, care, treatment, care, clinic/clinics, treat Barriers, legal/policy barriers, access, use/nonuse, utilization/utilise, seeking, ‘health services accessibility’
      Acceptability/acceptance, health knowledge/attitudes/practice, perception, belief, ‘attitude of health personnel’
       STD specific terms
      Sexually Transmitted Disease (STD)/Sexually Transmitted Infection (STI)/Reproductive Tract Infection (RTI), Chlamydia, Gonorrhea, Syphilis, HPV, HSV, HIV
      Table 2Inclusion and exclusion criteria
      CriteriaInclusionExclusion
      Time frame2001–presentPre–2001
      Study populationStudies where the primary population of interest is: Adolescents (10-24)
      Note: Youth up to age 24 years were included per UNESCO definition of youth (http://www.unesco.org/new/en/social-and-human-sciences/themes/youth/youth-definition/). Married and unmarried youth were also included given high rates of HIV among married women in some countries [9].
      , male or female.

      Health care providers (e.g., doctors, nurses, midwives, community health workers)
      Studies on the general or adult population.
      Study designQualitative studies using methods such as: interviews, focus groups, or group activities. The studies include participants' own words about their perspectives and use qualitative analysis methodology.

      Or

      Quantitative studies that use surveys to capture attitudes related to access and services.
      Articles that use quantitative methods that do not address attitudes/perceptions of barriers (e.g., demographic variations in use of services or modeling).

      Book reviews, literature reviews, conference papers, clinical trials, or intervention studies, policy documents.

      Gray literature, unpublished reports, or theses.
      STI/SRH careStudies with a major focus on barriers to or perceptions of STI services.

      Or

      Articles on barriers to sexual and reproductive health (SRH) services that, at a minimum, include STIs/STDs in the definition of SRH care in the introduction and include some reference to STDs in the results (e.g., burning symptoms, STI services, condoms access, STI education).
      Studies with a major focus on access to specific SRH services such as HIV or contraception.
      Barriers/useThe focus of the study is on identifying perceived factors that impede or significantly delay accessing appropriate health care services.

      Studies that assess youth perceptions (or services provider perceptions) related to SRH/STI services for youth. Or the study solicits input on what would make services more youth friendly (e.g., perceptions of services, “youth friendliness”)
      Studies that focus on increasing use of services through specific program interventions.
      Knowledge/behavior (not necessary for Inclusion)Studies reporting knowledge of STIs and services as related to accessing care.

      Studies on individual SRH behaviors (e.g., condom use) as related to access to SRH care.
      Studies solely on knowledge of SRH/STI issues.

      Studies solely on SRH related behaviors.
      Geographic scopeDeveloping countries: Including the regions of Africa (North and sub-Saharan), Asia (South and Southeast), Oceania, Central and South America.Studies in the following countries/regions: United States, Canada, Europe, Australia, New Zealand, China, Japan, Hong Kong
      LanguageArticles written in EnglishArticles in all other languages
      STD = sexually transmitted disease; STI = sexually transmitted infection.
      a Note: Youth up to age 24 years were included per UNESCO definition of youth (http://www.unesco.org/new/en/social-and-human-sciences/themes/youth/youth-definition/). Married and unmarried youth were also included given high rates of HIV among married women in some countries
      • Clark S.
      Early marriage and HIV risks in sub-Saharan Africa.
      .
      We identified 2,932 studies through database search, hand searches, and reference or related article search (Supplemental Figure 1). After removal of duplicates, title, and abstract review, 2,790 studies were excluded because of irrelevance, language, population, geographic location, or primary focus. An additional 45 articles were excluded after a second full-text review. In total, 19 studies were identified for inclusion in the review from 15 countries and four world regions (Sub-Saharan Africa, South Asia, Southeast Asia, and the Pacific).

      Critical appraisal

      We assessed study quality by adapting several previous models [

      Critical Appraisal Skills Programme (CASP). Qualitative Research Checklist. Available at: http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. Accessed April 16, 2014.

      ,
      • Pluye P.
      • Gagnon M.-P.
      • Griffiths F.
      • et al.
      A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews.
      ,

      Joanna Briggs Institute (JBI). Qualitative Assessment and Review Instrument (QARI).

      ] into a framework that assessed studies on seven key criteria: research aims, appropriate methodology, sampling and recruitment strategy, data collection, data analysis, statement of findings, and reflexivity (Reflexivity, in qualitative studies, is the degree to which the authors are reflective on their own bias or judgment in conducting qualitative research [
      • Dixon-Woods M.
      • Sutton A.
      • Shaw R.
      • et al.
      Appraising qualitative research for inclusion in systematic reviews: A quantitative and qualitative comparison of three methods.
      ].) and consideration of bias [

      Critical Appraisal Skills Programme (CASP). Qualitative Research Checklist. Available at: http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. Accessed April 16, 2014.

      ,

      Joanna Briggs Institute (JBI). Qualitative Assessment and Review Instrument (QARI).

      ,
      • Dixon-Woods M.
      • Sutton A.
      • Shaw R.
      • et al.
      Appraising qualitative research for inclusion in systematic reviews: A quantitative and qualitative comparison of three methods.
      ,
      • Malterud K.
      Qualitative research: Standards, challenges, and guidelines.
      ] (Table 3). Mixed methods studies were assessed on both qualitative and quantitative criteria as well as on the integration of results [
      • Pluye P.
      • Gagnon M.-P.
      • Griffiths F.
      • et al.
      A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews.
      ]. Studies were classified as either primary (met all criteria) or secondary (lacked key methods information) quality. Secondary studies were included in thematic analysis but were not used to develop analytical themes. An overview of the 19 studies is provided in Table 4.
      Table 3Critical appraisal criteria
      Adapted from CASP (2014), Pluye (2009), and JBI (2014) [10–12].
      Criteria
      Aims1. Was there a clear statement of aims for the research?
      Appropriate methodology2. Is there justification provided for specific methods?
      • Does the research seek to interpret or illuminate the actions and/or subjective experiences participants?
      Sampling and recruitment3. Is there a clear explanation of sampling and recruitment strategy? (including sample size, characteristics, ethical issues, and so forth)

        Quantitative

      • Was a representative sample achieved (e.g., was the response rate sufficiently high)?
      Data collection4. Is it clear how the data were collected? (Including specific methodologies used, context, and who collected?)
      Analysis5. Is there a clear description of the analysis methods and process?
      Findings6. Is there a clear statement of findings?
      • Does the study present sufficient data to support the stated findings, and demonstrate that findings are grounded in data?

        Mixed methods

      • Does the article integrate findings from both methods?
      Reflexivity
      a Adapted from CASP (2014), Pluye (2009), and JBI (2014)

      Critical Appraisal Skills Programme (CASP). Qualitative Research Checklist. Available at: http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. Accessed April 16, 2014.

      ,
      • Pluye P.
      • Gagnon M.-P.
      • Griffiths F.
      • et al.
      A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews.
      ,

      Joanna Briggs Institute (JBI). Qualitative Assessment and Review Instrument (QARI).

      .
      Table 4Overview of studies included in synthesis (n = 19)
      Study author (date)Research aimPopulation of interestData collection methodsContextCountryRegionQuality
      Sub-Saharan Africa
       Alli (2013)To explore to what extent interpersonal relations form a barrier to young people's access to and satisfaction of health services among university students and providers.Adolescents
      Adolescents are defined as 10–24 for the purposes of this review.
      (18–24)

      Providers
      Providers category includes health service providers (doctors, nurses, health workers, and so forth), NGO workers, and teachers. Some studies also include community and parental attitudes but these are not the focus of this analysis.
      Qualitative:

      204 IDIs
      University health servicesSouth AfricaSouth AfricaPrimary
       Berhane (2005)To describe the health service utilization pattern of adolescents, assess their attitudes toward existing services, and their preference of services in terms of place, person and time.Adolescents

      (10–24)
      Quantitative:

      Survey

      (n = 2,647)
      Secondary schoolEthiopiaEast AfricaSecondary
       Biddlecom (2007)To assess adolescents' use of sexual and reproductive health services, the barriers they face in accessing such services and their opinions and preferences regarding different sources of care.Adolescents (12–19)Quantitative: survey

      n = 5,955 (BF)

      n = 4,430 (G)

      n = 4,031 (M)

      n = 5,112 (U)
      National surveysBurkina Faso (BF)

      Ghana (G)

      Malawi (M)

      Uganda (U)
      South AfricaPrimary
       Cherie (2012)To assess adolescents' knowledge of STI symptoms and identify perceived barriers to seeking STIs services among high school adolescents.Adolescents (15–24)Mixed methods:

      Survey (n = 316)

      4 FGDs (n = 38)
      Urban high schools and clubsEthiopiaEast AfricaPrimary
       Godia (2013)To assess perspectives and experiences of health service providers on the SRH needs of young people.ProvidersQualitative:

      19 IDIs

      2 FGDs

      (n = 38)
      Health facilitiesKenyaEast AfricaPrimary
       Godia (2014)To explore the SRH problems young people face as well as their perceptions of available SRH services. Compared experience with integrated and youth targeted SRH services.Adolescents (10–24)Qualitative:

      18 IDIs

      39 FGDs

      (n = 57)
      Health facilities and youth centersKenyaEast AfricaPrimary
       Kipp (2007)To assess providers' perceptions and attitudes of important barriers for adolescents in receiving good quality RH services. Also to assess providers' attitudes related to adolescent sexual behavior and RH.ProvidersQualitative:

      10 IDIs
      Health facilitiesUgandaEast AfricaPrimary
       Langhaug (2003)To explore the views of young people, nurses, and parents on the accessibility of existing reproductive health services for young people and the means for improving this.Adolescents (16–19)

      Providers
      Qualitative:

      10 FGDs

      16 direct observations
      Community FGDsZimbabweSouth AfricaSecondary
       Miles (2001)To understand the social processes that inform young people's sexual health-seeking behavior in rural areas with a focus on the influences of decision-making in relation to seeking advice and treatment for STIs.Adolescents (14–25)Qualitative:

      12 FGDs

      (n = 97)
      Village FGDsGambiaWest AfricaPrimary
       Molla (2009)To assess youth's use, perceptions of and preferences for STI services from the perspective of both youth and providers.Adolescents (15–24)

      Providers
      Mixed methods:

      Survey (n = 3,743)

      10 provider IDIs
      Village survey and health clinic interviewsEthiopiaEast AfricaPrimary
       Okereke (2010)To examine the unmet reproductive health needs and health-seeking behavior of adolescents.Adolescents (10–19)

      Providers
      Mixed methods:

      survey (n = 896)

      4 FGDs

      15 IDIs with providers
      Secondary school and community FGDs and surveyNigeriaWest AfricaSecondary
      Asia and the Pacific
       Char (2011)To investigate whether young unmarried rural men in India are underserved in terms of SRH issues. To review their knowledge, attitudes, and perceptions about SRH.Adolescents (17–22)

      Unmarried men
      Mixed methods:

      Survey (n = 316)

      4 FGDs
      Village FGDs and surveyIndiaSouth AsiaPrimary
       Kennedy (2013)To assess barriers to accessing SRH services and describes the features of a youth-friendly health service as defined by adolescents.Adolescents (15–19)

      Providers
      Qualitative:

      12 IDIs

      66 FGDs

      (n = 353)
      Community FGDsVanuatuPacificPrimary
       Nair(2013)To explore the perceived reproductive health problems, health-seeking behaviors, knowledge about available services, and barriers to reach services among adolescents.Adolescents (15–24)

      Providers

      Community
      Qualitative:

      15 FGDs
      Community FGDsIndiaSouth AsiaSecondary
       Prasad (2005)To investigate the prevalence of RTIs in young married women and understand treatment seeking behavior.Adolescents (16–22)

      Married women
      Mixed methods:

      Cross-sectional survey (n = 451),

      17 IDIs, 8 FGDs
      Community FGDs and surveyIndiaSouth AsiaPrimary
       Regmi (2010)To explore young people's perceptions of barriers to accessing sexual health services and information, including condom use.Adolescents (18–22)Qualitative:

      10 FGDs

      31 IDIs

      (n = 50)
      Colleges and youth clubsNepalSouth AsiaPrimary
       Talpur (2012)To assess attitudes toward services, awareness of and perceived barriers for sexual health services and education among young adults.Adolescents (16–25)Quantitative:

      Cross-sectional survey (n = 150)
      Academic institutionsPakistanSouth AsiaSecondary
       Tangmunkongvorakul (2005)To describe the experiences and perspectives of young people with regard to obstacles to their safe sexual health outcomes and desirable health services.Adolescents (17–20)Qualitative:

      82 IDIs
      Community interviewsThailandSoutheast AsiaPrimary
       Tangmunkongvorakul (2012)To understand gender double standards and the ways in which these constitute barriers to successfully accessing sexual and reproductive health services.Adolescents (14–20)Mixed methods:

      Cross-sectional survey,

      30 IDIs, 16 FGDs

      (n = 1,745)
      Community, nonformal educational centers, and schoolsThailandSoutheast AsiaPrimary
      FGD = focus group discussion; IDI = in-depth interview; RTIs = reproductive tract infection; SRH = sexual and reproductive health; STI = sexually transmitted infection.
      a Adolescents are defined as 10–24 for the purposes of this review.
      b Providers category includes health service providers (doctors, nurses, health workers, and so forth), NGO workers, and teachers. Some studies also include community and parental attitudes but these are not the focus of this analysis.
      Thematic analysis has been used previously in qualitative systematic reviews of health-related and similar topics [
      • Dixon-Woods M.
      • Agarwal S.
      • Jones D.
      • et al.
      Synthesising qualitative and quantitative evidence: A review of possible methods.
      ,
      • Hannes K.
      • Macaitis K.
      A move to more systematic and transparent approaches in qualitative evidence synthesis: Update on a review of published papers.
      ,
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ]. Thematic analysis involves identifying descriptive themes from the original data of other studies and developing overarching analytic themes that develop new concepts or explanations that apply across them [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ]. The results sections and accompanying tables of all studies (qualitative, quantitative, and mixed methods) were coded and analyzed qualitatively using thematic analysis. Study results were analyzed using NVivo10 software (Version 10; QSR International, Pty Ltd., Melbourne, Australia) to code and to organize themes. We identified key themes using both deductive structural codes, developed by the researchers and guided by the research questions and existing literature, as well as inductive codes that emerged from the data [
      • Hennink M.
      • Hutter I.
      • Bailey A.
      Qualitative research methods.
      ]. A pilot sample of primary quality studies was then coded independently by two researchers [A.N.L. and J.S.L.] and themes were further refined. Results or quotes that focused on specialized SRH services not related to STIs were not included in analysis. Once initial thematic analysis was complete, we grouped themes according to WHO classifications of quality health services [
      World Health Organziation (WHO)
      Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
      ] and those that were crosscutting for the framework.

      Results

      Of the 19 studies we analyzed (Table 4), 10 used qualitative methods only, three were quantitative only, and six used mixed methods. Twelve articles were published between 2008 and 2014. Six studies included health care providers as participants. Most studies included both boys and girls; one focused on married females and another on unmarried males only. Four studies focused on rural youth only, but the majority included youth from urban and rural areas. Five studies included young adolescents aged 10–12 years as participants.
      Health care providers were included in the study population in eight of the studies (Table 4). Providers included health service providers (doctors, nurses, health workers, and so forth), Non-governmental organization (NGO) workers, and teachers. We analyzed provider perceptions of the barriers that youth experience in accessing services and the providers' own perceptions of their SRH/STI service to youth.
      An overview of themes identified in each study is provided in Table 5. Themes are grouped into overarching categories based on WHO classifications of quality health services [
      World Health Organziation (WHO)
      Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
      ], as well as by inductive crosscutting themes that emerged from the data related to drivers of barriers such as knowledge and cultural influences. Adolescent and provider perspectives are both given for each theme, and providers' views on providing services to adolescents are discussed. Quotes are provided from original articles to illustrate themes.
      Table 5Overview of studies and major themes: Barriers to appropriate care seeking (n = 19)
      Study author (date)PopulationCross-cutting driversWHO barriers
      AdolescentsProvidersKnowledgeCultureAvailabilityAccessibilityAcceptabilityEquity
      Equity is included in the WHO categories of quality services but this review did not find significant discussion of this theme to merit a separate section. Discussion of differences in barriers experienced by males and females as well as urban and rural youth throughout the other sections of the article.
      ConfidentialityShame and stigmaProvider factors and treatmentGirls
      Sub-Saharan Africa
       Alli (2013)18–24XXXXXX
       Berhane (2005)10–24XXXX
       Biddlecom (2007)12–19XXXXX
       Cherie (2012)15–24XXXXXX
       Godia (2013)XXXXXX
       Godia (2014)10–24XXXXXX
       Kipp (2007)XX
       Langhaug (2003)16–19XXXXXXX
       Miles (2001)14–25XX
       Molla (2009)15–24XXXXXXX
       Okereke (2010)10–19XXXXXXX
      Asia and the Pacific
       Char (2011)17–22XXXX
       Kennedy (2013)15–19XXXXXXXX
       Nair (2013)15–24XXXXX
       Prasad (2005)18–22XXXX
       Regmi (2010)16–25XXXXXXX
       Talpur (2012)17–20XXXX
       Tangmunkongvorakul (2005)14–20XXX
       Tangmunkongvorakul (2012)16–22XXXXX
      WHO = World Health Organization.
      ❖ Providers included in study.
      — No youth included in study.
      X Theme identified in study.
      • Theme not found in study.
      a Equity is included in the WHO categories of quality services but this review did not find significant discussion of this theme to merit a separate section. Discussion of differences in barriers experienced by males and females as well as urban and rural youth throughout the other sections of the article.

      STIs among youth

      For the purposes of this review “having an STI” included those who reported that they had STI symptoms or indicated symptoms such as burning, itching, genital discharge, and those who had been diagnosed with an STI. Seven studies mention or give estimates of youth who have had an STI. The rates of infection varied widely, potentially due to the different time periods and subgroups studied [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Okereke C.I.
      Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria.
      ,
      • Prasad J.H.
      • Abraham S.
      • Kurz K.M.
      • et al.
      Reproductive tract infections among young married women in Tamil Nadu, India.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ].

      Knowledge and awareness

      Ten studies discussed knowledge and awareness as barriers to seeking care. In many, youth reported having limited knowledge of SRH problems [
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Char A.
      • Saavala M.
      • Kulmala T.
      Assessing young unmarried men's access to reproductive health information and services in rural India.
      ,
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ] and, specifically, STIs [
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Okereke C.I.
      Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria.
      ,
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ]. Some youth had heard of STIs, but a majority were unable to name symptoms or had misconceptions about them. In addition, youth were often more knowledgeable about contraception or HIV than STIs. A lack of knowledge was often associated with not seeking care or with delaying treatment.Everybody might have heard about HIV/AIDS. But very few have heard about other sexually transmitted diseases (NGOs/ Leaders, India) [
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ].
      Lack of knowledge about STI services was also a significant obstacle for youth [
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ]. Not knowing where to go for services or a lack of understanding about the services provided were identified as barriers to seeking SRH or STI care [
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ]. In some studies, youth reported that they were afraid to seek services because they did not understand what would happen during a clinic visit [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ].
      Parents and providers also presented impediments to knowledge if they were unwilling or unable to provide information about SRH. Youth reported that they wanted to get information from parents and providers but that they did not provide it [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ].
      Knowledge of STIs continued to be an issue over time for youth and did not seem to vary significantly by study publication date. This was problematic for both males and females; however, specific knowledge did vary by sex across studies; some found that boys knew more about STI symptoms [
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ], whereas others found that girls were more knowledgeable about SRH or where to go for services [
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ]. Knowledge barriers were also discussed more frequently in rural than urban settings.

      Availability

      Available health services mean that services and supplies exist at health centers [
      World Health Organziation (WHO)
      Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
      ]. In nine studies, both urban and rural youth and providers reported specific barriers related to availability of products and services. Staff shortages (including number of staff and staff time) were among the most commonly identified barriers [
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. Stock outs (running out of supplies) or limited funds were also noted as obstacles. Availability was an issue throughout regions but was most frequently discussed by East African studies.

      Accessibility

      Accessible health services mean that youth are able to obtain health services that are available [
      World Health Organziation (WHO)
      Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
      ]. Sixteen studies (Table 5) discussed accessibility of services, and among them, 12 identified accessibility as a barrier. Among the accessibility barriers most frequently mentioned were those related to cost of services [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ], hours services were offered [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ], and waiting times to receive services [
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ]. The locations of services, or issues related to transportation, were also sometimes mentioned. Providers also noted obstacles with accessibility [
      • Okereke C.I.
      Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria.
      ,
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. Accessibility issues were discussed by both sexes, though more frequently discussed by males, and were mentioned in both rural and urban settings, though more frequently in urban settings. Accessibility was an issue noted consistently over time.

      System barriers: clinic systems are not for youth

      Several studies identified system-specific barriers that prevented accessible care. Clinic systems often limited youth's access to services or were not set up to provide streamlined care for youth. Services sometimes lacked accommodations for age [
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ] or sex [
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ] or were not integrated with other services such as maternal health, family planning, or primary care, requiring youth to seek out specialized STI or sexual health services elsewhere. Having to seek specialized care often resulted in concerns about confidentiality [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ].It is apparent that the health needs of youth are ignored by the health care system. Once I went to one of the health institutions for a health problem. I was referred back and forth between adult and pediatric units because they both claimed serving only specific age categories… (Adolescent, 15-24, Ethiopia) [
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ].
      That clinic systems were not usually oriented to providing youth with sexual health services, frequently led to the perception that SRH services and the systems themselves were ‘not for youth,’ which overlapped with barriers related to acceptability of services [
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ].
      Many providers felt that they needed more training in working with youth and sometimes felt that those being trained were not necessarily those most in need of it [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. Some providers saw barriers in national health policies and guidelines. Other providers reported limited knowledge of national health policies and guidelines for providing SRH services to youth [
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ]. Discussions about policy frequently focused on “youth rights” with respect to SRH services and revealed a mixed level of acknowledgment that youth had a right to services or to confidentiality [
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ].

      Acceptability

      Acceptable health services mean that youth are willing to obtain the health services that are available

      Provider attributes

      Fourteen studies noted the importance of provider attributes for youth seeking SRH care [
      World Health Organziation (WHO)
      Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
      ]. Many youth and providers noted that youth did not feel comfortable speaking with a provider who they perceived to be much older [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ].I do not think that most young people go there for services because there are a very few young service providers. How can we express our feelings to the people who are similar to our parents' age? (Urban unmarried male aged 21 years, Nepal) [
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ].
      Some studies mentioned that having young providers (especially at youth centers or NGOs) were perceived by youth as facilitating access to care. Nine studies also noted that the provider's sex was a significant factor for youth [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Prasad J.H.
      • Abraham S.
      • Kurz K.M.
      • et al.
      Reproductive tract infections among young married women in Tamil Nadu, India.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ,
      • Talpur A.A.
      • Khowaja A.R.
      Awareness and attitude towards sex health education and sexual health services among youngsters in rural and urban settings of Sindh, Pakistan.
      ]. The ability to see a provider of the same sex was particularly a barrier for girls [
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ]. A few studies stated that some youth saw providers as having insufficient or no skills related to providing SRH services, counseling, and so forth [
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Talpur A.A.
      • Khowaja A.R.
      Awareness and attitude towards sex health education and sexual health services among youngsters in rural and urban settings of Sindh, Pakistan.
      ]. Provider attributes were referenced among both rural and urban populations and more frequently discussed by girls than boys.

      Provider behavior

      Thirteen studies cited provider behavior toward youth during SRH services. Most described providers as “judgmental” or “having a poor attitude.” Negative behaviors included: rude or unfriendly treatment, blaming, lecturing or scolding, or yelling at youth (Table 6). Barriers related to provider behavior were discussed by both boys and girls, and in both rural and urban settings, with studies in urban settings referencing these barriers more frequently. Reported provider behavior toward youth, however, varied by type of service provider. NGOs or specific youth service facilities were often noted as having friendlier providers [
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ]. Public services, on the other hand, were more often discussed in relation to provider treatment barriers. In one study, youth mentioned that there had been an improvement among providers at public government clinics, potentially due to increased training [
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ].
      Table 6Provider behavior with young clients
      ThemeQuote
      Citations illustrative not inclusive.
      Rude or unfriendly
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      “The staff are too tense and not friendly enough. They do not give you advice; it is more like they judge you” (Female Client, 18, South Africa).
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      Yelling or shouting
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      “I had a friend who once got an STI. He tried to get condoms but the nurses would not allow him. Later he went with an STI and they shouted at him. He [reminded] them that he came trying to find condoms and information and they had refused saying he was still young (Male Student, 16–19, Zimbabwe).”
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      Lecturing or scolding
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      “Sometimes they [nurses] talk strongly to young people and tell them ‘it's good you are getting this [STI] because you sleep around too much’” (Female 18–19, FGD, Vanuatu).
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      Blaming
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      “I need someone to talk to me nicely. My friend used to go to the hospital. When she got a vaginal exam, she was scared. The nurse yelled at her. The hospital staff were not so nice although we paid for the service. They asked us ‘why didn’t you think before sleeping with somebody?’ That hurt.” (Female, 16, Thailand)
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      a Citations illustrative not inclusive.

      Provider perspectives on delivering services

      Providers also discussed their own attitudes about delivering SRH/STI services to youth. Health services providers frequently mentioned that attributes such as age and sex [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ], as well as provider behavior toward youth, could be impediments to youth seeking SRH care. Some providers acknowledged that youth needed to feel welcomed to come back for services [
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ]. Although this was recognized by some providers, others (and even some of the same providers themselves) also acknowledged that they judged or lectured youth when they came in for STI/SRH care [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ].Because if you are a young boy or young girl and you go there asking for family planning or condoms and the nurse might say “you are a young girl or young boy so you don’t need to use that. Like if I was a nurse in community and see young people coming, I will not agree for young people to be practicing sex at a very early age. Because some of our nurses in our communities they will not allow and they will talk. If the nurse's attitude is different to what young people are thinking then it's a barrier (Nurse, Vanuatu) [
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ].
      This judgment was related to role definition. Providers often mentioned that they felt that youth saw them as a parental figure or that they saw themselves as taking on a parental role [
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ]. Challenges with regard to role definition were linked to difficulty in communicating with youth and providing them appropriate SRH counseling.

      Confidentiality

      A total of 16 studies discussed confidentiality and 14 specifically noted confidentiality as a barrier to care. Youth's concerns with confidentiality were both about the potential of being seen or overheard and about the provider's ability to ensure confidentiality [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Cherie A.
      • Berhane Y.
      Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Char A.
      • Saavala M.
      • Kulmala T.
      Assessing young unmarried men's access to reproductive health information and services in rural India.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. Youth frequently feared being seen by friends and other members of the community, particularly by those who could tell their parents.
      Some youth also discussed that services or condoms were provided without privacy where one could be observed and that names were called loudly by the clinic staff [
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ,
      • Tangmunkongvorakul A.
      • Banwell C.
      • Carmichael G.
      • et al.
      Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
      ]. Several studies noted that youth were actually concerned that providers would tell someone about their STI:If you go with an STD to the local clinic, they may send the information to our headmaster (male student, FGD). The nurses will send [your] name to the school and the issue will be discussed by teachers (female student, FGD) (Youth, 16-19, Zimbabwe) [
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ].
      Confidentiality issues were tied to larger fears related to community perceptions and ultimately to stigma. Providers frequently noted youth's fears as well [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Nair M.K.C.
      • Leena M.L.
      • George B.
      • et al.
      ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ].The reason they may not go to the community is because in the village information spreads like bushfire … by the time I buy the condom or go to the health unit-the person in the health unit is well known to everyone-and if I go there to get a condom, I will be tagged as a wrong person in the community because our society is not yet fully open to discussing sex freely … (Provider, Uganda) [
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ].
      Youth in both urban and rural settings described barriers related to confidentiality, although in some instances urban youth claimed that they were able to access services, especially condoms, anonymously [
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ]. Confidentiality concerns did not seem to vary significantly by region or over time. Both male and female youth were concerned with confidentiality. Confidentiality concerns were also more frequently mentioned in relation to public services, whereas private services were sometimes seen as better at protecting it.

      Stigma and shame

      The prevailing barrier, discussed in every study, to accessing SRH/STI services was stigma and shame. Shame and stigma are related but distinct. Stigma can be defined as “an attribute or label that sets a person apart from others and links the labeled person to undesirable characteristics” [
      • Fortenberry J.D.
      • McFarlane M.
      • Bleakley A.
      • et al.
      Relationships of stigma and shame to gonorrhea and HIV screening.
      ,
      • Lewis M.
      Shame and stigma.
      ]. Stigma occurs in the public sphere and is manifest at a community or society level. Shame occurs at an individual level and has been defined as a negative emotion having to do with the experience of failure in relation to personal or social standards and the feeling of responsibility for such failure [
      • Lewis M.
      Shame and stigma.
      ].
      Twelve studies discussed stigma in relation to seeking SRH or STI care. As noted previously, youth were often very concerned about being recognized by their communities, parents/relatives, friends, or community leaders; being seen could result in gossip and judgment both associated with stigma [
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ].
      Youth most frequently described experiencing stigma from providers, feeling they were being labeled as promiscuous or “a bad person” or telling stories about being openly humiliated [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ,
      • Tangmunkongvorakul A.
      • Banwell C.
      • Carmichael G.
      • et al.
      Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
      ].Sometimes they [nurses] talk strongly to young people and tell them ‘it's good you are getting this [STI] because you sleep around too much’” (Female 18–19, Vanuatu) [
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ].
      Seeking services for SRH or STIs was also noted as problematic because it served as evidence of sexual behavior. This resulted in stigma, often from providers—who did not condone sexual behavior for youth, either because they were seen as too young or because they were having sex before marriage [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ,
      • Tangmunkongvorakul A.
      • Banwell C.
      • Carmichael G.
      • et al.
      Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
      ].Respondent (R2): The nurse-midwife only goes to see married people and women who are pregnant. Who comes to ask what we want? We're very shy to even approach these people for a condom. It would mean that we were doing something wrong. […]If someone saw me buying a condom, word would spread (Unmarried Male, India) [
      • Char A.
      • Saavala M.
      • Kulmala T.
      Assessing young unmarried men's access to reproductive health information and services in rural India.
      ].
      In some cases, youth and providers reported that stigma resulted in providers denying services to youth [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ].
      For the purposes of this review, we have combined results for shame and embarrassment. Feelings of shame experienced by youth in accessing SRH/STI services included those of embarrassment, self-stigma, fear, and feeling “ashamed.” Youth and providers frequently reported embarrassment as a driving factor in delaying or not accessing care [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. This included embarrassment about seeking care, answering questions from providers related to symptoms or sexual activity, or buying condoms [
      • Berhane F.
      • Berhane Y.
      • Fantahun M.
      Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
      ,
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Tangmunkongvorakul A.
      • Banwell C.
      • Carmichael G.
      • et al.
      Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
      ]. In six studies, shame was also expressed as fear of seeking services [
      • Biddlecom A.E.
      • Munthali A.
      • Singh S.
      • et al.
      Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
      ,
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ,
      • Godia P.
      • Olenja J.
      • Hofman J.
      • et al.
      Young people's perception of sexual and reproductive health services in Kenya.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Talpur A.A.
      • Khowaja A.R.
      Awareness and attitude towards sex health education and sexual health services among youngsters in rural and urban settings of Sindh, Pakistan.
      ]:We have a belief that doctors may ask different questions. We always feel fear when answering these questions; so, we rarely go to them [clinics]. We especially feel too shy to share our sexual behaviours with those doctors (Rural married females, 15-24, Nepal) [
      • Regmi P.R.
      • van Teijlingen E.
      • Simkhada P.
      • et al.
      Barriers to sexual health services for young people in Nepal.
      ].
      In a few instances shame was also associated with infidelity. Youth (both married and unmarried) feared seeking services for STIs because it would signify infidelity [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ]. This shame was especially a concern to women:[. . .] How can I seek healthcare for STIs while I am married and still living with my husband? It is a shame for me (Male Nurse quoting a female patient, Ethiopia) [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ].
      Studies also noted that young women experienced more shame and stigma and were often judged more harshly than young men [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ,
      • Tangmunkongvorakul A.
      • Banwell C.
      • Carmichael G.
      • et al.
      Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
      ].I really didn’t understand why the nurse yelled at me when I told her that it hurt when she gave me a vaginal examination. I felt like she didn’t want to provide services to an indecent girl like me [said with tears in her eyes]… She [the nurse] said I should behave well, so I wouldn’t get into trouble next time (Female, High school student, Thailand) [
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ].

      Culture

      Culture, social norms, and taboos related to adolescent sexuality were described as barriers by both youth and providers. The prevailing norm, that youth should not be sexually active or use SRH services, frequently made it hard for youth to access care and for providers to deliver it [
      • Okereke C.I.
      Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria.
      ,
      • Char A.
      • Saavala M.
      • Kulmala T.
      Assessing young unmarried men's access to reproductive health information and services in rural India.
      ,
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. This norm was often related to youth being “too young” or unmarried.
      Taboos about adolescent sexuality were also frequently tied to pressures from religious leaders or parents in the community. Parents were noted as being against youth sexual activity, as evidenced by their refusal to discuss sex or to provide sexuality education [
      • Langhaug L.
      • Cowan F.
      • Nyamurera T.
      • et al.
      Improving young people's access to reproductive health care in rural Zimbabwe.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Kipp W.
      • Chacko S.
      • Laing L.
      • et al.
      Adolescent reproductive health in Uganda: Issues related to access and quality of care.
      ]. Providers too felt that they could not discuss sexuality due to cultural and often religious norms.…the important reproductive health issues I don’t talk about because I am not allowed to talk about condoms. I don’t feel good. We have many problems but we don’t talk about them…some communities and churches you can't (Nurse, Vanuatu) [
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ].
      Although norms and sexual taboos were challenges for both young men and women, young women were subject to higher expectations related to their sexuality, and these cultural challenges have persisted over time. Studies published before 2007 and after noted that community norms and the providers' own values posed significant barriers to youth. One study in Kenya, however, found that providers supplied condoms readily:For the male [condom] if at all she ask me for it, I can give, and because she is asking for a family planning method. If at all, I test a client and she becomes [HIV] positive I normally provide the condoms so that they can use with the partner,… so that I normally give them the condoms for prevention of STI and other problems (Provider, Nairobi) [
      • Godia P.M.
      • Olenja J.M.
      • Lavussa J.A.
      • et al.
      Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
      ].
      Providers from the same study, however, reported that they viewed family planning as something that should not be given to youth. It should be used by married people only.
      Taboos and social norms drove many other barriers for youth seeking STI/SRH care. Cultural and social norms deepened fears about confidentiality and community judgment, impacted provider behavior toward youth, and were a primary source of youth's experiences of stigma and shame.

      Discussion

      Our review of qualitative and mixed methods research focusing on barriers to STI services among youth in low- and middle-income countries identified several studies conducted in Africa and Asia. Young people in these countries continue to experience significant barriers in accessing STI/SRH services, including a lack of knowledge about STIs and lack of awareness of STI services. Previous research focusing on in-school adolescents in Europe and the United States also found a lack of awareness and knowledge about STIs [
      • Samkange-Zeeb F.N.
      • Spallek L.
      • Zeeb H.
      Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: A systematic review of published literature.
      ,
      • Cohall A.
      • Kassotis J.
      • Parks R.
      • et al.
      Adolescents in the age of AIDS: Myths, misconceptions, and misunderstandings regarding sexually transmitted diseases.
      ]. Our review also identified reported barriers to STI services among young people in each of the WHO categories focusing on quality and friendliness in health services: availability, accessibility, acceptability, and equity. Several studies, for example, found issues related to service availability (e.g., supplies, staff shortages), and in most studies, young people identified barriers to accessibility, including cost of services and in some studies clinic system barriers related to a lack of service integration. A previous review of various health services in Uganda also found that cost and shortages were barriers to accessing health care. In addition, a study in the United States found that cost was also a barrier to STI services; however, young people were often aware of free services provided by health departments [
      • Tilson E.C.
      • Sanchez V.
      • Ford C.L.
      • et al.
      Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions.
      ]. In their nonsystematic review, Hock-Long et al. found that cost was less of a barrier for adolescents accessing reproductive health services in Western Europe. A previous review of school health services identified studies in the United States and United Kingdom which found fewer barriers related to cost and availability of other SRH services [
      • Hock-Long L.
      • Herceg-Baron R.
      • Cassidy A.M.
      • et al.
      Access to adolescent reproductive health services: Financial and structural barriers to care.
      ,
      • Carroll C.
      • Lloyd-Jones M.
      • Cooke J.
      • et al.
      Reasons for the use and non-use of school health services: As systematic review of young people's views.
      ].
      The most common barriers identified in our review were related to acceptability of services. Provider characteristics and behaviors led some young people to fear accessing services. Clinic systems and provider actions also resulted in significant concerns about confidentiality. These findings are supported by several previous studies that reported fears about confidentiality as barriers to youth seeking STI services in the United States, United Kingdom, and Canada [
      • Hock-Long L.
      • Herceg-Baron R.
      • Cassidy A.M.
      • et al.
      Access to adolescent reproductive health services: Financial and structural barriers to care.
      ,
      • Carroll C.
      • Lloyd-Jones M.
      • Cooke J.
      • et al.
      Reasons for the use and non-use of school health services: As systematic review of young people's views.
      ,
      • Shoveller J.
      • Johnson J.
      • Rosenberg M.
      • et al.
      Youth's experiences with STI testing in four communities in British Columbia.
      ]. Furthermore, a study in Uganda found that confidentiality was a concern of STD patients of all ages [
      • Kiwanuka S.N.
      • Ekirapa E.K.
      • Peterson S.
      • et al.
      Access to and utilisation of health services for the poor in Uganda: A systematic review of available evidence.
      ]. Ultimately, experiences of shame and stigma were the most powerful barriers to seeking STI and SRH services for young people. These findings were supported by other reviews focusing on SRH services across the world and various health services in Uganda [
      • Bearinger L.H.
      • Sieving R.E.
      • Ferguson J.
      • et al.
      Global perspectives on the sexual and reproductive health of adolescents: Patterns, prevention, and potential.
      ,
      • Kiwanuka S.N.
      • Ekirapa E.K.
      • Peterson S.
      • et al.
      Access to and utilisation of health services for the poor in Uganda: A systematic review of available evidence.
      ]. Previous research in the United States has shown that stigma about STIs can result in delayed care seeking [
      • Fortenberry J.D.
      Health care seeking behaviors related to sexually transmitted diseases among adolescents.
      ,
      • Cunningham S.D.
      • Kerrigan D.L.
      • Jennings J.M.
      • et al.
      Relationships between perceived STD-related stigma, STD-related shame and STD screening among a household sample of adolescents.
      ]. A separate study found that shame may be a greater barrier to seeking services for asymptomatic as compared with symptomatic STI [
      • Tilson E.C.
      • Sanchez V.
      • Ford C.L.
      • et al.
      Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions.
      ]. Although these barriers are similar to those experienced by young people in seeking other reproductive health care (e.g., contraception), youth lack knowledge related to STIs and STI services, and this can lead to a lack of recognition and use of services.
      In terms of equity in access to services, some populations did experience more barriers than others, notably young females were reported to experience stigma from providers more frequently than young males [
      • Molla M.
      • Emmelin M.
      • Berhane Y.
      • et al.
      Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
      ,
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ,
      • Tangmunkongvorakul A.
      • Kane R.
      • Wellings K.
      Gender double standards in young people attending sexual health services in Northern Thailand.
      ,
      • Tangmunkongvorakul A.
      • Banwell C.
      • Carmichael G.
      • et al.
      Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
      ]. Barriers to appropriate STI care persist for both young males and females and for both urban and rural populations. Little variation in barriers was found over time, suggesting that efforts to address access to STI services have been limited. STI services, moreover, are not integrated within the health care system. Because services are siloed, young people cannot access services easily and risk being identified as seeking STI care. They often perceive STI and SRH health care as not for them because systems do not exist, cultural taboos forbid adolescent sexuality, or services are not youth friendly.
      Themes identified as barriers for youth were also reflected in the providers' own assessments. Providers knew youth lacked knowledge of SRH/STI services and reported they often felt uncomfortable providing services to youth. Many acknowledged that they judged youth when they sought care. A study of youth-friendly services in South Africa found that providers reported lack of confidentiality, staff shortages, and the need for a separate space as barriers to STI services [
      • Geary R.S.
      • Gomez-Olive F.X.
      • Kahn K.
      • et al.
      Barriers to and facilitators of the provision of a youth-friendly health services programme in rural South Africa.
      ]. Providers are an essential component to increasing adolescent access to services. Adolescents need providers with whom they feel comfortable sharing intimate details. Gender considerations are especially important but so is the treatment that adolescents receive when they come in for services. Many providers also voiced discomfort with their competency in providing services, a discomfort which might be mitigated through appropriate training. In some of the most recent studies, we also found a shift occurring for some, where youth reported that they were treated well especially by NGO workers [
      • Alli F.
      • Maharaj P.
      • Vawda M.Y.
      Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
      ] or noted recent improvements in treatment from other providers [
      • Okereke C.I.
      Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria.
      ]. Some providers also acknowledged a shift in their understanding of youth rights [
      • Kennedy E.C.
      • Bulu S.
      • Harris J.
      • et al.
      “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
      ].
      Our study has some limitations. Given our exclusion criteria, we excluded studies evaluating interventions and community projects. By excluding these studies, we may have missed nuances in barriers to services and could have missed some information on what the most significant or changeable barriers are for adolescents. We were also unable to identify any English language studies from Latin America and thus were unable to include any studies that represent that region of the world. Finally, our review consists mainly of qualitative studies, and may not be generalizable to all youth in these areas.
      Our findings have substantive implications for STI and SRH health services for youth in middle- and low-income countries. The most significant barriers to youth's access to STI services are rooted in cultural norms and stigma. Increasing adolescent access to STI services will require significant work to address clinic systems and provider attitudes, especially with respect to protecting adolescent confidentiality. Addressing barriers to STI services, moreover, will necessitate addressing cultural norms related to adolescent sexuality. The complementary issues of strengthening both the quality-of-health service provision and of improving community support for the provision of health services to adolescents are in line with the recommendations of by Denno et al. [
      • Denno D.M.
      • Hoopes A.J.
      • Chandra-Mouli V.
      Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support.
      ].
      Adolescent SRH is higher on the global development agenda than ever before. In 2010, for example, the United Nations Secretary General launched the Global Strategy for Women's and Children's Health to increase efforts to achieve Millennium Development Goals 4 and 5. As we move from Millennium Development Goals to new Sustainable Development Goals, a new Global Strategy for Women's Children's and Adolescents' Health has been developed and agreed on [
      United Nations
      Global strategy for women's, children's and adolescents' health – 2016 to 2030. Survive, thrive and transform.
      ]. The renewed strategy has a strong focus on adolescents. In the United Nations Secretary General's words: “The updated Global Strategy includes adolescents because they are central to everything we want to achieve, and to the overall success of the 2030 Agenda.”
      The strategy focuses on survival (ending preventable mortality), on thriving (enabling children, adolescents, and adults to achieve the highest standard of health), and on transformation (achieving transformative and sustained change). This focus provides a critical opportunity for support of policy reform, integrated health services delivery, and innovative approaches to health system staffing and structure to more adequately address STI prevention for adolescents in low- and middle-income countries.

      Supplementary Data

      References

        • World Health Organziation (WHO)
        Global incidence and prevalence of selected curable sexually transmitted infections – 2008.
        (Geneva, Switzerland)2012
        • Centers for Disease Control and Prevention
        Sexually transmitted disease surveillance 2013.
        U.S. Department of Health and Human Services, Atlanta, GA2014
        • United Nations
        UN interagency task team on HIV and young people. Guidance brief: HIV interventions in the health sector.
        United Nations, New York2007 (Available at:) (Accessed July 5, 2015)
        • Bearinger L.H.
        • Sieving R.E.
        • Ferguson J.
        • et al.
        Global perspectives on the sexual and reproductive health of adolescents: Patterns, prevention, and potential.
        The Lancet. 2007; 369: 1220-1231
        • Mbizvo M.T.
        • Zaidi S.
        Addressing critical gaps in achieving universal access to sexual and reproductive health (SRH): The case for improving adolescent SRH, preventing unsafe abortion, and enhancing linkages between SRH and HIV interventions.
        Int J Gynaecol Obstet. 2010; 110: S3-S6
        • World Health Organziation (WHO)
        Global consultation on adolescent friendly health services: A consensus statement.
        Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland2001
        • Dehne K.L.
        • Riedner G.
        Sexually transmitted infections among adolescents : The need for adequate health services.
        World Health Organization, Geneva, Switzerland2005
        • World Health Organziation (WHO)
        Making health services adolescent friendly: Developing national quality standards for adolescent-friendly health services.
        Department of Maternal, Newborn, Child and Adolescent Health, Geneva, Switzerland2012 (Available at:) (Accessed July 5, 2015)
        • Clark S.
        Early marriage and HIV risks in sub-Saharan Africa.
        Stud Fam Plann. 2004; 35: 149-160
      1. Critical Appraisal Skills Programme (CASP). Qualitative Research Checklist. Available at: http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf. Accessed April 16, 2014.

        • Pluye P.
        • Gagnon M.-P.
        • Griffiths F.
        • et al.
        A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews.
        Int J Nurs Stud. 2009; 46: 529-546
      2. Joanna Briggs Institute (JBI). Qualitative Assessment and Review Instrument (QARI).

        • Dixon-Woods M.
        • Sutton A.
        • Shaw R.
        • et al.
        Appraising qualitative research for inclusion in systematic reviews: A quantitative and qualitative comparison of three methods.
        J Health Serv Res Policy. 2007; 12: 42-47
        • Malterud K.
        Qualitative research: Standards, challenges, and guidelines.
        Lancet. 2001; 358: 483-488
        • Dixon-Woods M.
        • Agarwal S.
        • Jones D.
        • et al.
        Synthesising qualitative and quantitative evidence: A review of possible methods.
        J Health Serv Res Policy. 2005; 10: 45-53
        • Hannes K.
        • Macaitis K.
        A move to more systematic and transparent approaches in qualitative evidence synthesis: Update on a review of published papers.
        Qual Res. 2012; 12: 402-442
        • Thomas J.
        • Harden A.
        Methods for the thematic synthesis of qualitative research in systematic reviews.
        BMC Med Res Methodol. 2008; 8: 45
        • Hennink M.
        • Hutter I.
        • Bailey A.
        Qualitative research methods.
        Sage, Thousand Oaks, CA2011
        • Berhane F.
        • Berhane Y.
        • Fantahun M.
        Adolescents' health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely.
        Ethiop J Health Dev. 2005; 19: 29-36
        • Biddlecom A.E.
        • Munthali A.
        • Singh S.
        • et al.
        Adolescents' views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda.
        Afr J Reprod Health. 2007; 11 (DOI: PMCID: PMC2367115): 99-110
        • Cherie A.
        • Berhane Y.
        Knowledge of sexually transmitted infections and barriers to seeking health services among high school adolescents in Addis Ababa, Ethiopia.
        J AIDS Clin Res. 2012; 3
        • Molla M.
        • Emmelin M.
        • Berhane Y.
        • et al.
        Readiness of youth in rural Ethiopia to seek health services for sexually transmitted infections.
        Afr J AIDS Res. 2009; 8: 135-146
        • Okereke C.I.
        Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria.
        Afr J Reprod Health. 2010; 14: 43-54
        • Prasad J.H.
        • Abraham S.
        • Kurz K.M.
        • et al.
        Reproductive tract infections among young married women in Tamil Nadu, India.
        Int Fam Plan Perspect. 2005; 31: 73-82
        • Regmi P.R.
        • van Teijlingen E.
        • Simkhada P.
        • et al.
        Barriers to sexual health services for young people in Nepal.
        J Health Popul Nutr. 2010; 28: 619-627
        • Char A.
        • Saavala M.
        • Kulmala T.
        Assessing young unmarried men's access to reproductive health information and services in rural India.
        BMC Public Health. 2011; 11: 476
        • Nair M.K.C.
        • Leena M.L.
        • George B.
        • et al.
        ARSH 5: Reproductive health needs assessment of adolescents and young people (15–24 y): A qualitative study on 'perceptions of community stakeholders'.
        Indian J Pediatr. 2013; 80: S214-S221
        • Langhaug L.
        • Cowan F.
        • Nyamurera T.
        • et al.
        Improving young people's access to reproductive health care in rural Zimbabwe.
        AIDS Care. 2003; 15: 147-157
        • Godia P.
        • Olenja J.
        • Hofman J.
        • et al.
        Young people's perception of sexual and reproductive health services in Kenya.
        BMC Health Serv Res. 2014; 14: 172
        • Kennedy E.C.
        • Bulu S.
        • Harris J.
        • et al.
        “Be kind to young people so they feel at home”: A qualitative study of adolescents' and service providers' perceptions of youth-friendly sexual and reproductive health services in Vanuatu.
        BMC Health Serv Res. 2013; 13: 455
        • Alli F.
        • Maharaj P.
        • Vawda M.Y.
        Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care.
        J Community Health. 2013; 38: 150-155
        • Godia P.M.
        • Olenja J.M.
        • Lavussa J.A.
        • et al.
        Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.
        BMC Health Serv Res. 2013; 13: 476
        • Kipp W.
        • Chacko S.
        • Laing L.
        • et al.
        Adolescent reproductive health in Uganda: Issues related to access and quality of care.
        Int J Adolesc Med Health. 2007; 19: 383-393
        • Tangmunkongvorakul A.
        • Kane R.
        • Wellings K.
        Gender double standards in young people attending sexual health services in Northern Thailand.
        Cult Health Sex. 2005; 7: 361-373
        • Talpur A.A.
        • Khowaja A.R.
        Awareness and attitude towards sex health education and sexual health services among youngsters in rural and urban settings of Sindh, Pakistan.
        J Pak Med Assoc. 2012; 62: 708-712
        • Tangmunkongvorakul A.
        • Banwell C.
        • Carmichael G.
        • et al.
        Use and perceptions of sexual and reproductive health services among northern Thai adolescents.
        Southeast Asian J Trop Med Public Health. 2012; 43: 479-500
        • Fortenberry J.D.
        • McFarlane M.
        • Bleakley A.
        • et al.
        Relationships of stigma and shame to gonorrhea and HIV screening.
        Am J Public Health. 2002; 92: 378-381
        • Lewis M.
        Shame and stigma.
        in: Gilbert P. Andrews B. Shame: Interpersonal behavior, psychopathology, and culture. Oxford University Press Inc., New York, NY1998: 126-137
        • Samkange-Zeeb F.N.
        • Spallek L.
        • Zeeb H.
        Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: A systematic review of published literature.
        BMC Public Health. 2011; 11: 727
        • Cohall A.
        • Kassotis J.
        • Parks R.
        • et al.
        Adolescents in the age of AIDS: Myths, misconceptions, and misunderstandings regarding sexually transmitted diseases.
        J Natl Med Assoc. 2001; 93: 64-69
        • Tilson E.C.
        • Sanchez V.
        • Ford C.L.
        • et al.
        Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions.
        BMC Public Health. 2004; 4: 21
        • Hock-Long L.
        • Herceg-Baron R.
        • Cassidy A.M.
        • et al.
        Access to adolescent reproductive health services: Financial and structural barriers to care.
        Perspect Sex Reprod Health. 2003; 35: 144-147
        • Carroll C.
        • Lloyd-Jones M.
        • Cooke J.
        • et al.
        Reasons for the use and non-use of school health services: As systematic review of young people's views.
        J Public Health. 2011; 34: 403-410
        • Shoveller J.
        • Johnson J.
        • Rosenberg M.
        • et al.
        Youth's experiences with STI testing in four communities in British Columbia.
        Sex Transm Infect. 2009; 85: 397-401
        • Kiwanuka S.N.
        • Ekirapa E.K.
        • Peterson S.
        • et al.
        Access to and utilisation of health services for the poor in Uganda: A systematic review of available evidence.
        Trans R Soc Trop Med Hyg. 2008; 102: 1067-1074
        • Fortenberry J.D.
        Health care seeking behaviors related to sexually transmitted diseases among adolescents.
        Am J Public Health. 1997; 87: 417-420
        • Cunningham S.D.
        • Kerrigan D.L.
        • Jennings J.M.
        • et al.
        Relationships between perceived STD-related stigma, STD-related shame and STD screening among a household sample of adolescents.
        Perspect Sex Reprod Health. 2009; 41: 225-230
        • Geary R.S.
        • Gomez-Olive F.X.
        • Kahn K.
        • et al.
        Barriers to and facilitators of the provision of a youth-friendly health services programme in rural South Africa.
        BMC Health Serv Res. 2014; 14: 259
        • Denno D.M.
        • Hoopes A.J.
        • Chandra-Mouli V.
        Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support.
        J Adolesc Health. 2015; 56: S22-S41
        • United Nations
        Global strategy for women's, children's and adolescents' health – 2016 to 2030. Survive, thrive and transform.
        United Nations, New York2015