Recommendations for removing access barriers to effective Sexual/Reproductive Health Services (SRHS) for young people in South East Nigeria: A systematic review

Young people’s Sexual and Reproductive Health (SRH) services in Nigeria are limited and there are issues of affordability and accessibility of these health services. Also, there are limited studies in Nigeria on the barriers to accessing and utilizing SRHS in the Nigerian healthcare sector. Furthermore, even when the services are provided they are not sensitive to the needs of young people. Hence, this study aims to assess the barriers to the availability and accessibility of sexual reproductive health services (SRHS) for young people living with sexually transmitted infections (STIs) in Abia State, Nigeria.

Study Aim: To make recommendations for removing assess barriers to effective sexual and reproductive health services for young people living with STIs in southeast Nigeria.

Methodology: A systematic review of 14 studies comprising 9 qualitative studies, 3 mixed methods, 1 quantitative and 1 cross-sectional study. The inclusion criteria were primary studies written in the English language which assessed barriers to SRH services while the exclusion criteria were the secondary studies and primary studies which did not access barriers to accessibility and availability of SRHS for young people. A total of 4, 705 participants from different African countries formed the sample size.

Findings: Results showed that young people have little or no insight into STIs and their services. Moreover, they experienced different levels of barriers ranging from the negative and judgmental attitude of healthcare providers, stigma, cost, availability and accessibility of healthcare services as well as lack of integration of services and privacy and confidentiality. These are the major barriers that discourage young people from accessing SRH services. Also, experiences of fear and shame were reported as common barriers to utilizing care.

Conclusion: Sensitizing the SRH needs of young people can enhance access to healthcare services. Therefore, there is a need to improve uptake and address the negative attitude of healthcare providers, as well as the issue of confidentiality, which will help to improve SRH service utilization among young people. Also, it is recommended that teaching health care professionals about these STI prevention centers will be the main solution to improve the preventive practice to reduce STI incidence in young people in Nigeria.

Introduction and background

Unsafe sexual behavior is a predisposing factor to the high prevalence of Sexually Transmitted Diseases (STIs), Human Immunodeficiency Virus (HIV) and unwanted pregnancies. Sexual reproductive health (SRH) constitutes a major component of the global disease burden in Africa [1]. The sexual reproductive health services (SRHS) in Nigeria are often underutilized despite young people’s needs. Hence, young people face many challenges while accessing SRHS that are supposed to be youth friendly in Nigeria. Abajobir and Seme [2] affirm that even though the services are underutilized the few services available are underutilized. Eremutha and Gabriel [3]; Tylee, et al. [4] stated that young people are often discouraged from accessing SRHS due to time constraints, cost and fears about a breach of confidentiality, embarrassment, sociocultural norms regarding sexual activities of young people and poor awareness of the services.

There are multitudes of barriers contributing to the availability and accessibility of SRHS among young people. In Nigeria, young people face many significant problems like limited access to youth-friendly services which include unsafe abortion, family planning and sexuality [5]. This has led to risky sexual behavior resulting in a high prevalence of STIs and HIV, unwanted pregnancy and delivery complications leading to an increased rate of morbidity and mortality among young people [6]. Availability of these services is therefore important for young people in Nigeria. Although, these services are provided by the Nigerian healthcare system the services are not specifically for young people [7].

To meet WHO recommendations, the healthcare sector in Nigeria, the Federal Ministry of Health Nigeria (FMoHN) introduced a health policy to address sexual reproductive health services that is youth-friendly in the primary healthcare center to ensure the availability, accessibility, and quality of young people’s SRH in Nigeria [8]. However, since the introduction of these services the utilization of SRH by young people is extremely low. Notable findings from previous studies revealed that young people experienced different challenges in seeking SRHS in Nigeria which includes little or no knowledge about SRH and poor health-seeking behavior [9,10]. They also experience a lack of confidentiality [11], an absence of services required by young people [10] and a negative attitude towards healthcare providers [12-14]. This study aims to assess the barriers to the availability and accessibility of SRHS for young people living with STIs in Nigeria and make some recommendations. To contribute to making Nigerian healthcare services more accessible to young people (Figure 1).

Figure 1: The Theoretical Framework using the Tanahashi model for evaluating health service coverage.

The review applies the Tanahashi model [15] to evaluate the barriers to availability and accessibility of SRHS among young people through the five key approaches which reflect various steps along the healthcare service provision continuum. These 5 phases represent a link between the healthcare system and the people in ways gaps can be identified in service delivery.

Availability coverage

Despite the need for young people to access SRHS, their services are relatively low [16]. This is a result of a lack of knowledge of SRHS for young people or skills in providing appropriate care to young people by healthcare providers or due to negative attitudes of the healthcare providers [17]. Also, due to integrated services where young people access adult SRH services, they feel there is a lack of privacy, hence feel shy to discuss their SRH problems with the healthcare providers [17]. In many developing countries, there is a lack of capacity to provide enough human resources such as skilled doctors, nurses, and midwives to provide SRH services. Supplies of modern contraceptives and drugs are often erratic and poor infrastructure can inhibit access to services [18].

Isiugo-Abanihe, et al. [19] affirmed that poor access to young people’s SRH services like health education on STI prevention and treatment and the use of contraceptives can help prevent some complications. Poor utilization and low access to SRHS by young people have been attributed to a lack of availability of services and social and cultural norms limiting access to SRHS [12]. Also, Agampodi and Agampodi [20] confirm that most countries in Africa lack sufficient trained personnel who will provide and care for the SRH needs of young people.

Accessibility coverage

Access to SRH services by young people in Nigeria is relatively very low, particularly in remote areas [21]. Lack of access to SRH services contributes to high levels of morbidity and mortality for mainly preventable SRH problems. Young people should be able to access SRH services that are youth-friendly [22]. However, SRH services are not often available to young people in many resource-constrained settings in Nigeria, due to some factors such as geographic and financial accessibility [23]. Also, Odo, et al. [24] emphasized that SRHS is not financially accessible to young people with low income.

Financial accessibility means using one’s money to pay for consultation fees, laboratory costs, and paying for prescriptions, most young people do not work and can’t afford to pay medical bills, and most times, their access to care is dependent on parental consent [25]. In Nigeria, healthcare financing is remarkably inadequate and contributes to the instability of the healthcare sector. Many households depend on out-of-pocket expenditure as less than 5% of Nigerians are covered by National Health Insurance Scheme (NHIS) [26]. Affordability of healthcare continues to be a challenge for most young people in Nigeria due to insufficient funds to cover healthcare costs and travel [27].

Additionally, in the rural setting, young people cover long distances to health facilities thereby forgoing their comfort time and money to seek healthcare [25]. This correlates with the study of Thongmixay, et al. which affirms that young people in the rural area indicated that clinics were hard to reach and lack infrastructure. Also, FMOHN stated that distance to health facilities poses a barrier to access to healthcare needs. As this will deter them from seeking healthcare services. A Focused Group Discussion (FGDs) cited distance as a major factor why young people patronize patent/pharmacy shops over visiting healthcare facilities [25].

Acceptability coverage

Availability and accessibility of SRHS may not be acceptable for young people for some reasons like the negative attitude of healthcare providers, cultural beliefs about perceptions of health needs, concerns about confidentiality, and stigmatization. When health needs are related to a stigmatized health issue, this may discourage young people from communicating the need for services [25]. Stigma has been recognized as a major barrier to accessing HIV prevention, care, and treatment services. Yet, little attention has been given to the effect of stigma on young people’s access to SRH services [28]. Odimegwu, et al. [29] showed that HIV/AIDs patients avert utilization of voluntary counseling and testing in Nigeria due to stigmatization. This means that young people seeking healthcare have experienced social stigma, particularly when seeking services for STIs. Furthermore, Starrs, et al. [30] and Nyblade, et al. [31] affirm that unmarried young people accessing SRHS are particularly vulnerable to stigma leading to shame, fear, and verbal harassment. By accepting young people to access healthcare facility that is free from stigma, healthcare professionals are contributing to young people’s well-being and their ability to make informed decision regarding their health.

Healthcare providers’ negative attitude has significantly impacted young people’s access to SRHS and has been cited as a major barrier to obtaining contraceptives and family planning age Speizer, et al. [32] at health facilities. Also, healthcare providers were perceived to be judgmental when young people visit the SRH services [33]. This judgmental attitude was evident in the study of Langhaug, et al. [34] which shows that healthcare providers experience role conflict while dealing with the Reproductive Health (RH) of young people. Langhaug further stressed that nurses assume parental responsibility thereby refusing to provide condoms and contraceptives to them.

Thus, there is a conflict between professional and cultural beliefs in delivering RH to young people. These cultural contexts result in young people being uninformed about sexuality issues and prevent them from utilizing the SRHS [2]. These predispose them to a high risk of SRHS issues like sexually transmitted infections (STIs), HIV and AIDS, unsafe abortion, unwanted pregnancies, and other SRH issues that could be life-threatening [35]. The increase in the rate of SRH issues among young people in Nigeria is alarming and suggests the need for adequate attention to young people’s SRH needs. Also, healthcare providers asserted that young people who visit SRH services use slang that they do not understand [36] thereby making the provision of healthcare difficult.

The feeling of shame, fear of privacy, unfriendly healthcare providers, and lack of confidentiality are perceived reasons young people do not access SRH services leading to unwanted pregnancies and difficulties obtaining contraceptives from health centers [37]. Young people believed that their confidentiality is breached when it comes to sexuality matters [38]. Young people further asserted that some healthcare providers ask them to come with their parents and some stated that they fear they may inform their parents [33]. As such making young people seek treatment from other sources like herbalists [39].

Contact and use coverage

The knowledge about SRH among young people is of paramount importance to addressing health policies, and initiatives and developing evidence-based programs to address young people’s needs [40]. However, the knowledge of SRH among young people is poor [41]. Njoroge, et al. [42]; Motuma [43] confirmed that young people lack basic knowledge of SRH and have little or no access to affordable SRH services. This correlates with the findings of Stella, et al. [44] and Sibanda, et al. [45] who stated that young people were less experienced, less comfortable, and less informed in accessing and utilizing SRH services.

Centre for Population and Environmental Development (CPED) [46] in its policy identified a lack of awareness about where to obtain contraceptives and treatment for STIs as one of the reasons for the underutilization of services. Notably, the study by the United Nations Population Fund [47] found that boys were not accessing SRH services because they perceived the services to be designated only for girls and women. Also, some young people can be affected by a lack of contact due to a lack of awareness of SRH [48]. Young girls in the northern part of Nigeria [49], and young people with a low level of education [50] fall into this category.

Effective coverage

Effective coverage can be influenced by a variety of factors which include healthcare provider’s compliance and patient treatment [24]. This review shows that young people do not go to health facilities due to shame, stigma, lack of respect by healthcare providers, and lack of confidentiality. This inhibits young people from adhering to the prescribed treatment, and as such, they prefer to buy medicines from chemists/pharmacies in Nigeria due to free unrestricted access to medications and no law stops them. Evidence suggests that there are issues concerning effective treatment and its ability to achieve the desired outcome. FMoHN [8] identified inadequate support for young people’s health by healthcare providers as a barrier to effective coverage. Furthermore, young people in rural areas are not being reached with accurate SRHS information.

Inadequate human resources, medicine, and trained healthcare providers were found to be another barrier to effective coverage. Otovwe and Elizabeth [51] opined that there is a lack of adequately trained medical personnel and diagnostic services were grossly lacking. Additionally, inadequate human resources and failure to provide adequate SRH services to young people can result in suboptimal compliance and concerns about the quality of care. Low levels of manpower have also been associated with low health service effectiveness [52].

Aim

To assess the barriers to availability and accessibility of SRHS for young people living with STIs in Abia State, Nigeria.

Objectives of the study

• To systematically review recent primary research articles on the barriers that mitigate against accessibility and availability of SRHS for young people in Nigeria.
• To explore the barriers experienced by young people in accessing SRHS in Abia State Nigeria.
• To ascertain the attitudes of healthcare providers toward the availability and accessibility of SRHS in Nigeria.
• To analyze the impact of SRHS on young people.

Research question

What are the barriers to accessibility and availability of SRHS for young people living with STIs in Abia State Nigeria?

Inclusion criteria and exclusion criteria

Inclusion and exclusion criteria are specifications made by a researcher in advance before the commencement of a literature search to prevent ambiguity. They help to identify relevant articles that address the research question and those that are not applicable to it. It is essential to set out clear and appropriate inclusion and exclusion in any research to ensure that the review remains focused and that only articles that meet pre-specified criteria are included in the study [53]. In addition, the application of inclusion and exclusion criteria in a study allows the researcher to show details and scope of the review which may serve as important evidence for the generalizability and relevance of the study [54]. Hence, below is a table of systematic inclusion and exclusion considered for this study(Tables 1,2).

Materials and methods

Search strategy

A comprehensive literature search was conducted using PEO terms from 12/09/2020 to 20/11/2020 on several databases. The search engines used are Discover powered by Ebsco and PubMed Central, and attempts were made to search Science Direct MEDLINE and CINAHL. However, most of the generated articles were duplicates of the same articles from PubMed Central or Discover search engines. Although, google may be regarded as an invalid database for scientific research; but, further search was done on this website to create a highly sensitive search result as well as prevent the risk of search prejudice. However, most of the generated studies were duplicates or newsletters from different organizations.

A further search was conducted on Information of Grey Literature in Europe (SIGLE) to identify unpublished research studies that may be relevant to the topic under study. However, no research article that is relevant to the research topic was identified in this database.

On the first computer search, Boolean operators ‘’OR’’ and ‘’AND’’ was applied using the keywords and their synonyms; barriers, access, young people, and SRHS [55]. Other search terms used are barriers or challenges, access or limiting, young people or youths, SRHS or youth-friendly clinics STIs, and STDs. The same search strategy was applied to other databases used for this study. The purpose of using basic Boolean operators like “OR”, and “AND’’ to combine different keywords was to generate appropriate results; thus saving time and effort by eliminating irrelevant hits [53].

In addition, the use of ‘AND’ provided more opportunities to add more keywords in search engines like PubMed; however, the researcher applied caution while using these Boolean operators in some search engines by ensuring that the right databases can interpret the relationship between the used keywords were utilized. This is to avoid generating unwanted studies or eliminating useful articles that will be relevant to the study as indicated by Hancock, et al. [56], who suggest that it is essential that researchers use a database that permits an advanced search when using Boolean operators to ensure that the relationships of the used keywords display relevant articles.

The search made on Discover and PubMed Central generated a total of 1704 with Discover yielding 983 articles and 721 with PubMed Central starting from 1989 to 2020. The articles were further reduced to 10 years from 2010 to 2020 and a total of 540 articles were eliminated. At this stage duplicates of 318 articles were removed. The researcher further decrease the articles to 30 by discarding 816 articles by restricting the search words and their synonyms to the title through the advanced search option. A further advanced search was done by limiting the search to pre-specified inclusion and exclusion criteria such as peered-reviewed, English language and full-text articles.

30 articles were critically explored by their titles, abstracts, texts and the authors’ affiliation. If the abstract suggests potential eligibility, the full article was retrieved, while those that do not fit the inclusion criteria were excluded. This reduced the article to a total of 23 studies. These articles were printed out and critically assessed through thorough reading to retrieve relevant articles that meet the required criteria for the study. Finally, a total of 14 articles were selected, while the remaining 7 articles were excluded because of not meeting the quality assessment, the participants used in the study were young people. Nevertheless, all the excluded studies were reserved to be used during the discussion of this study. The selected studies include 9 qualitative studies, 3 mixed methods, 1 cross-sectional study and 1 quantitative study (Figure 2).

Figure 2: Prisma 2009 flow diagram.

Data analysis

This chapter aims to critically synthesize the results of the reviewed articles and compare them with other systematic reviews that are applicable to answer the research question. A total of 14 articles were included in this systematic review. 9 of the studies are qualitative studies, 1 cross-sectional study, 1 quantitative study and 3 mixed method studies with similar objectives which aim to examine the barriers to accessibility and utilization of SRHS among young people and few variances in the research aims. The total number of participants used in the study was 4,705 which was generated from the 14 reviewed primary studies. Also, the studies considered in this review were conducted across sub-Saharan Africa ranging from Nigeria, Ghana, Ethiopia, the Democratic Republic of Congo and Kenya. This is conducted to get a wide range of perceptions regarding the barriers to accessing SRHS among young people (Figure 3).

Figure 3: Names of authors and sample sizes.

Themes

Different themes were generated from the findings in the reviewed research articles which were evidence of the barriers to availability and accessibility of SRHS for young people as applicable to Abia State, Nigeria. These themes will be discussed below.

Provision of SRHS and STIs related services

The provision of youth-friendly SRH services by ensuring quality healthcare, availability, and accessibility are essential for young people to live healthy life. WHO [57,58] stated that inadequate provision of SRH services for young people increases the risk of STIs, HIV, unwanted pregnancies, and unsafe abortion. Also, the inability to access SRH services can lead to young people getting inaccurate SRH information from their mates and uninformed people [20]. Furthermore, the review cited barriers to accessing SRH services including the cost of services and lack of service integration [59]. The study by Abuosi and Anaba [60] and Mutea, et al. [61] found that financial challenges and lack of privacy in the clinic were barriers to accessing SRH services for many young people due to the high rate of unemployment [62], shortage of staff leading to long waiting times [61,63,64], lack of information [65] and lack of skilled service providers [62].

In addition, a study conducted in the US revealed that cost was one of the major barriers to STIs/SRH services; albeit young people were aware of the free services provided by the department of health [66]. Another review showed that the cost and availability of other SRH services were found to have fewer barriers in countries like US and United Kingdom [67,68].

Lack of knowledge of SRHS/STIs

Lack of awareness about SRH and where to access the services hinder young people’s use of the health facility. The majority of the participants perceived that the STIs and SRHS are not for them as the services are youth-friendly [69]. This is consistent with the study of Kennedy, et al. [70] as young people feel that the services are only for married people and mothers and not for young people. Also, lack of knowledge about what they would be asked and how to talk to healthcare providers is another reason for not accessing services [70]. This also corresponds with the study of Odo, et al. [24] that older people access SRHS more than young people, this is linked to the study of Abebe and Awoke, (2014)[71] that there is a low level of SRH services access among young people. Also, this result agrees with the result of studies conducted in Nigeria and Kenya which affirms that SRH services are not specifically designed for young people’s use [24,64]. This study is, however, similar to the findings of the study by Agampodi, et al. [20] in their in-depth interview and focus group discussions (FGDs) that young people who participated in the study were silent and had little knowledge of the majority of the problem discussed. These findings could be related to poor sex education received in both home and school. Additionally, there is also inadequate knowledge about contraceptives and condoms [62,72].

Furthermore, healthcare providers knew that young people lack knowledge of STIs/SRH services and reported feeling uncomfortable providing services to them [69]. Also, in some studies, young people reported being treated well by healthcare providers, especially by NGO workers [73], noted recent improvement from other healthcare providers [74] and some providers also acknowledged a shift in the understanding of young people’s rights [62].

Accessibility of SRH services by young people

Overall, the selected studies acknowledged accessibility as a barrier. Most frequently mentioned accessibility barriers to SRH services include the high cost of medical bills and the inability to afford the healthcare services at the health center are barriers to access [36,60-62,65,75-78]. Although, Okereke [74] stated in his study reported that the cost of contraceptives was reduced but young people prefer to buy the drugs in the pharmacy than going to the health center, this is a result of inappropriate channels of information dissemination that do not ensure accessibility to STIs information. However, Obong and Zani [64] stated that their participants reported that the medical bills were affordable. Another barrier is the location of the healthcare facility, transportation, and long queues were pointed out as one of the barriers [3,24,36,61,62,65,77]. This is supported by the study of Alli, et al. [73] that distance to health facilities and transportation was noted as an obstacle to accessing SRH care centers, while other respondents stated that they might be seen by parents or guardians or their friends who might mock them [64].

Availability of SRH services by young people

Five articles reported that one of the barriers to SRH services for young people is the availability of products and services in their area [3,24,60,74,77] and shortage of staff [73]. Similarly, Abuosi, and Anaba [60] in their study reported that young people experience facility-level barriers such as lack of space and privacy as the clinic for young people was used for multiple purposes such as consultation and library. These inconveniences young people due to lack of privacy, poor ventilation and overcrowding. Odo, et al. [24] Mentioned that sexuality education was not provided in the health facility rather they got sexuality education through health-related subjects and in the churches during their interview with their participants.

Although, some people believe that providing students with information on sexuality and how to use contraceptives will encourage immoral and health-compromising sexual habits which will increase the rates of STIs and unwanted pregnancies [79]. Some healthcare providers stated that it would be inappropriate for young people to access SRHS because they are considered to be too young to make sexual-related decisions [72]. This correlates with the findings from the other studies that young people cannot access SRH services without parental consent [13,80]. In addition, some studies reported that the opening hours are not convenient for them as the operating time for the health center is during school hours and they do not open on public holidays and weekends [60,76].

Also, participants reported limited times for interactions during SRH visits, this is because of a shortage of staff providing SRH care to young people [72]. This is in line with the study of Agampodi and Agampodi [20] which reported that there is a shortage of trained healthcare providers that will provide care and support for the SRH needs of young people. Furthermore, some studies reported that young people complained that the SRHS information provided to them was not clear [81,82]. Some of the respondents stated that pharmacies and patent shops provide more information to them than public clinics [83]. This correlates with the findings from the study of Thatte, et al. [81] which assert that majority of the boys felt that both private and public care staff do not provide them with adequate information about the use of contraceptives and STIs prevention. As a result of this, young people feel that they were been discriminated against as they are not married [78]. In contrast, Obong and Zani [64] reported that their participants stated that service providers provided more time for interaction with young people, though mentioned a low percentage of trained staff.

The availability of SRH services is an issue in most African countries. This is in line with the study of Tylee, et al. [4] which reported that SRH services are not available in most developing and sub-Saharan African countries. As the provision of SRH services to young people in Africa is still hindered by some restrictive laws and health policies [84,85]. Also, because African culture and societal norms prohibit pre-marital sex, most young people with sexuality issues prefer to seek advice from friends and close family members or use service deliveries like patent medicine dealers or pharmacies rather than seeking help from health centers due to fear [4,86].

Barriers to accessing SRHS services

Also, young people reported feeling ashamed, afraid, fearful, and embarrassed about accessing SRH services [60,62,64,81,83]. This emotional feeling was a result of healthcare providers’ negative attitude toward young people [64]. This relates to some studies that identified fear of being seen by parents or familiar people as being worrying to young people [64,78,87] and this serves as a barrier to access SRHS. This is seen in the study of Mbeba, et al. [78] where 72% of the respondent reported fear of being seen by parents or familiar faces they know hinders their access to SRH care.

Additionally, the long waiting hour spent in the clinics deters young people from access to SRHS [36,61,78,86]. Long waiting times can worsen the feeling of fear, embarrassment, and shame among young people who access SRH services. In the study by Mbeba, et al. [78] and Godia, et al. [36], it was stated that one of the male respondents mentioned that they feel uncomfortable staying in the same waiting room with women.

Furthermore, privacy and confidentiality are other worrying barriers to young people’s access to SRHS. Mutea, et al.; Godia, et al.; Kennedy, et al.; Muanda, et al.; Abubakari, et al. [36, 61,62,87,88] in their systematic review asserted that it could be a link to the negative attitude of healthcare providers. Young people are concerned with their confidentiality issues especially as regards to care provider’s ability to ensure that their privacy and confidentiality are not breached [89,90,91], or even seen in the clinic and been heard talking to the healthcare provider about their sexuality [92,93]. Also, in the studies of Kipp, et al. [91] and Tangmunkongvorakul, et al. [94] mentioned that young people complained that services were provided without privacy and names are called loudly by healthcare workers. Also, Newton-Levinson, et al. [59]in their systematic review affirmed that confidentiality concerns were mostly seen in public clinics while private clinics protect the privacy of their clients.

Attitudes of healthcare providers

Eleven studies discussed healthcare practitioners’ negative attitudes towards young people during SRH services. Many respondents refer to healthcare providers’ behavior towards them as being “judgemental” or “negative attitude”; some of the negative attitudes include scolding young people, blaming, unfriendly welcome, and rude attitude. This is experienced by both young boys and girls. As a result of these negative behavior young people feel ashamed, and embarrassed and this made it difficult for them to access SRH services [37,95]. This is in compliance with the study of Abuosi and Anaba [60]; Godia, et al. [36] which suggests that young people were labeled with bad names and perceived as being bad boys and girls. The community frowns at premarital sex and as a result of that, they stay away from the services in order not to be labeled.

Some studies also indicated that healthcare providers believe that parental consent needs to be sought before providing SRH services to young people [96], this will increase the risk of young people utilization of unsafe and illegal healthcare services in cases of abortion [97]. Although, Zainudin, et al. [98] opined that young people below the age of 18 years are considered minors and have no capacity to provide consent, thus requiring parental consent before healthcare services are delivered to them. Also, some respondents stated that they don’t access SRHS because some of the healthcare providers are older than them [81,82] and they feel uncomfortable speaking to a much older practitioner [36,73,99]. This corroborates the findings of Regmi, et al. [90] one youth said that they see older healthcare providers as people who care about their parents’ age. In addition, healthcare providers also feel the same way, as they feel that young people see them as parental figures rather than healthcare providers [34,36]. Furthermore, some healthcare providers acknowledged that they judge when they sought for SRH/STIs care [36,60,62].

Also, healthcare providers believe that teaching young people about sexuality would promote sexual activities [64]. As a result young people are being turned away when they seek STIs and abortion services [88]. From the reviewed studies young people stated that the lack of care and abusive words they experience from healthcare providers discourages them from accessing SRHS care [13,64].

Discussion

The review generated six themes of barriers that hamper young people from accessing SRH services: accessibility of SRH services by young people- this discourages young people from accessing SRH services; provision of SRHS and STIs related services- this implies availability of services, quality of service and experiences young people encounter while accessing SRHS; lack of knowledge of SRHS/STIs- to ascertain their knowledge about SRH/STIs services and where they can find it in their locality.

Healthcare providers’ negative attitude to young people accessing SRH services dominated all the barriers reported by young people. Most participants indicated fear of judgemental attitude and unfriendly welcome as a great influence on their uptake and satisfaction with SRH services [62,77]. The negative attitude of healthcare providers care facilitates or constitutes a barrier to young people accessing SRH services [100] Young people reported that healthcare providers are not sympathetic or show less empathy to them when they present a case to them at the health center. Some also reported several abusive words and being scolded by healthcare providers [62,64,75]. Some reported that they were being turned away when they seek for abortion, contraceptives, or other STIs services [62]. The review showed that this is a major barrier among young people when seeking SRH services in Africa [13,64].

Young people also stated that most healthcare providers do not give them the full information they needed and are not providing them with adequate SRH services and sometimes they will not provide any information. Some respondents indicated that their reason for not accessing SRH services is as a result of not being informed resulting in low utilization of SRH services [72]. On the contrary, Mbadu, et al. [75] think that some young people are aware of the services and contraceptives. Furthermore, Nmadu, et al. [76] asserted that young people avoid SRH services due to fear of being scolded and misjudged by healthcare workers. Conversely, young people mentioned having mixed experiences with healthcare providers [75].

Privacy and confidentiality are other strong barriers to care from the review. Young people were concerned about confidentiality as they don’t want their personal information to be shared with other people or be heard when discussing their health issues [61,74,77,90], as they don’t want to be seen by friends or a familiar face in the clinic. This is in line with the study of Godia, et al. [77] who states that the majority of the boys complained that they avoid the services because they do not want to be tossed around from one department to the other. Also, young people are afraid of being a victim of community gossip or seeing people that will tell their parents when they utilize SRH services [62]. Also, lack of privacy and inconvenient opening hours of SRHS has been identified in this study and is similar to reports of previous studies [76,101].

Young people may not want to seek services where there is a breach of confidentiality. The study of Mbadu, et al. [75] reveals that young people are particularly concerned about their confidentiality. In the study by Tangmunkongvorakul, et al. [94] and Langhaug, et al. [34], young people reported that their services in the clinic were not private, and their names were mentioned loudly by the clinic staff. Albeit, in the study of Regmi, et al. [90] that young people in the urban setting stated that the services rendered to them were confidential. In contrast, Gonçalves, et al. [102] in their study stated that a young girl’s confidentiality was breached when a GP shared information with her aunt. Another challenge young people face is sharing clinic space with adults who sees them as bad people [77]. These findings are evidenced by more recent studies that social stigma, self-stigma, and fear are barriers to SRH usage [103,104].

Lack of awareness also emerges as a barrier to accessing SRH services. The study .of Abuosi, and Anaba [60] revealed that some young people did not seek a visit to SRH because they were unaware of the services. Also, Godia, et al. [77] assert that inadequate information on reproductive health is part of the problem young people face when seeking SRH services. Okereke [74] indicated that young people’s inability to utilize or receive SRH services is an indication that there is an absence of proper counseling or adequate health education about sex and reproductive health. Additionally, young people reported that a lack of awareness about SRH services is a reason for not utilizing services [62]. Stigma and discrimination equally emerge as a barrier to seeking SRH services. Young people reported that stigma is one of the driving factors for delay or not accessing SRH services [60,62,91]. Utilizing services such as SRHS or STIs was seen as an issue as it is evidenced by sexual misbehavior [59]; thus regarded as stigma particularly by providers who do not accept sexual behavior from young people, either due to having premarital sex or they are regarded as too young to indulge in such activities [34,94,105]. This is evidenced by young people reporting in the studies of Molla, et al. [99]; Kennedy, et al. [62]; Tangmunkongvorakul, et al. [105] that due to stigma young people were being denied by healthcare providers.

Furthermore, stigma is also rooted in cultural norms, as young people should not be seen discussing sexuality since it is regarded as taboo in most African and Asian countries [106]. Additionally, the study of Ndayishimiye, et al. [72] stated that due to cultural norms it is not easy for young people to access SRHS because they can be seen as sex workers and young people with low life and it is also regarded as a sin.

Young people mention financial constraints as a barrier to accessing SRH services. As a result of unemployment, most young people reported that they cannot ask their parents for money to attend SRH services [62,76]. Also, Mutea et al. [61] stated in their study that cost deters young people from accessing SRH services as one of the barriers cited in their study. Although, in the study of Okereke [74], it was mentioned that cost is not an issue as the drugs and services are cheap. Also, Odo, et al. [24] stated that one-third of their respondents indicated that they can’t afford the cost of SRH services, although, they still claim that cost is not a barrier in their study.

The majority of young people stated that they could not afford SRH services due to unemployment. Finlay, et al. [107] affirmed that people with higher incomes can access SRH services more than those with no or little income. This is supported by Bernstein [108] that lower-income negatively affects young people’s access to SRHS. Thus, this finding is consistent with the results of Kennedy, et al. [62] that cost is a barrier to young people’s access to SRHS. Also, young people stated that paying for transport fares to where they can utilize SRHS is a barrier and other indicated that they have to walk a long distance to get to the health facility [109-113].

Last but not the least, the findings from the review showed that young people’s access to SRH services is restricted by many challenges like the judgmental and negative attitude of healthcare providers, stigma and discrimination, lack of information about SRH, and lack of finance. All the above have proved to be a major barrier to young people’s access to SRH services [62,83]. From this review, there should be healthcare intervention that will enhance accessibility and utilization of healthcare services among young people, creation of awareness about SRH in the communities, positive reinforcement to healthcare workers, and training to be able to accept and educate young people in good decision making.

Limitations of study

This review was conducted by only two researchers, thus there is a chance of bias due to subjectivity, in the methodology. Notwithstanding, efforts were made to prevent subjectivity and maintain accuracy through the use of recommended guidelines. Due to the knowledge gap observed in this area, the researchers retrieved a few articles that were directly related to the research question. Some of the articles could not be utilized because they were either obsolete or not primary research. Also, only articles written in the English Language were utilized, this would have permitted language bias. However, bias was minimized by the researcher by extracting relevant information from the studies reviewed. Ultimately, this review consists mainly of qualitative research studies and may not be generalized to the general population.

Implication to practice

There is a need for healthcare providers to undergo some specific training in youth counseling skills and interpersonal communications.

Inculcating SRH education in the school’s curriculum, by making teachers understand the importance of seeking SRH services also enables care providers to adapt to the needs of young people, especially their preventive health needs.

Healthcare providers need to understand young people’s knowledge, and their perception of health needs to provide them with adequate care.

Government should create awareness and provide youth-friendly SRH to reinforce positive attitudes.

Healthcare providers should reinforce youth-friendly attitudes among youth healthcare providers. This can be achieved through job training, the use of incentives, and negative reinforcement.

Conclusion

SRH services are a substantial public issue, and most young people from Nigeria are still being affected. The negative attitude of healthcare providers and lack of availability and accessibility of SRH services revealed that young people do not visit healthcare centers for SRHS/STIs because the majority of young people are not aware of its existence.

Based on the reviewed articles, it has been cited that young people face many barriers when accessing SRH services. The review identified significant results as regards barriers to SRH services by young people. Also, most of the challenges that impede young people when accessing SRH services could be linked to negative attitudes of healthcare providers as well as lack of accessibility and availability of SRHS. These barriers indicate that there is a need to increase access to SRH services that will meet global standards for SRH for young people. Therefore, there is a need for training healthcare providers on the importance of youth-friendly SRH services and creating awareness of the importance of health education for young people, so that they can access SRH services to improve acceptance.

Also, parents, teachers and other care providers need to be sensitized to help young people attain their healthcare needs. This study will provide useful information for healthcare practitioners and policymakers, especially those who are responsible for young people’s health.

Recommendations

Based on the findings of this study, it is recommended that teaching health care professionals about these STI prevention centers to improve the preventive practice to reduce STI incidence in young people in Nigeria will be the main solution. Also, the following recommendations have been highlighted to improve young people’s access to SRH services:

Improving the quality of service delivery for young people

There is a need for the government to provide youth-friendly SRH services for young people in Nigeria. This can be achieved by providing training to healthcare providers with current knowledge and practice to provide adequate youth-friendly facilities. The government should provide adequate resources for the smooth running of SRH services for young people. These include the use of contraceptives, drugs, counseling services, voluntary testing and screenings for HIV and STIs, and an adequate workforce (Tables 3,4).

Providing young people with proper health education and information about SRH services

Government should provide school-based SRH education and counseling that will bridge the gap in young people’s knowledge about SRH education and services. There is a need for the Nigerian ministry of health to collaborate with the ministry of education to disseminate SRH information on the availability of services using workshops, seminars, adverts and mass media for young people’s awareness. This would improve young people’s access to SRH services and information.

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