Adolescent and youth-friendly health interventions in low-income and middle-income countries: a scoping review

Abstract

Background

Adolescents comprise one-sixth of the world’s population, yet there is no clear understanding of the features that promote adolescent-friendly services (AFS). The lack of clarity and consistency around a definition presents a gap in health services.

Methods

The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a scoping review of peer-reviewed empirical studies to explore AFS in low-income and middle-income countries (LMICs) published between January 2000 and December 2022. The databases searched were CAB Direct (n=11), CINAHL (n=50), Cochrane Databases (n=1103), Embase (n=1164), Global Health Medicus (n=3636) and PsycINFO (n=156). The title, abstract and full text were double screened by three independent reviewers. Three independent reviewers assessed the study’s quality using the Joanna Briggs Initiative Quality Appraisal and Cochrane Risk of Bias 2 tools.

Results

We identified the key components, barriers and facilitators of AFS. The following emerged from our review: a non-judgmental environment, culturally appropriate and responsive interventions and a focus on supporting marginalised communities often living in high-poverty settings. Using these components, we have extended guidance around a possible framework and tool assessing quality of AFS.

Interpretation

As LMICs are heterogeneous and unique, it was assumed that the operational definition of ‘adolescent-friendly’ might vary depending on different contexts, but there must be core components that remain consistent. Possible limitations of our review include a lack of grey literature. Potential future implications include training healthcare providers, testing these attributes for service improvement and future development and localisation of policy guidelines.

Key highlights

Our review has mapped the research framing of AFS and provided a comprehensive review of barriers and facilitators to implementing a holistic outlook of AFS set-up in a tightly controlled research and real-world context. Our paper is one of the few efforts to synthesise behavioural and mental health elements underpinning AFS.

CJ and RS are joint first authors.

What is already known on this topic

• Adolescent friendly services (AFS) are recognized as being central to making services accessible and acceptable to young people. However, distillation of evidence-informed adolescent friendly services and how mental health or behavioral components, and strategies inform and underpin these services is not clearly understood. Our scoping addresses this gap.

What this study adds

• Our study provides in-depth examination of the barriers and facilitators of AFS while mapping the findings of key research studies from LMICs that address AFS in their intervention implementation and pulls together recommendations of key international adolescent health and development agencies. Our review findings are that AFS is about fostering a welcoming and non-judgmental environment, providing culturally appropriate and responsive services, and focused support for marginalised communities as it is especially needed within high-poverty settings. We would like to underscore that these services need strong and well-planned mental and behavioral health strengthening within LMICs to empower adolescents and youth.

How this study might affect research, practice or policy

• There remains a gap between how academic research, policy guidelines and existing practices focus on implementation of AFS. Our review points to synergies that the fields need to create for effective and engaged adolescent friendly services in LMICs. Without cross-sectoral evidence-synthesis, service barriers in low resource settings and vulnerable adolescents youth cannot benefit.

Background

Lessons from adolescent health fields suggest that adolescent mortality causes, especially in low-income and middle-income countries (LMICs), are largely preventable and treatable.¹ Thus, providing interventions during adolescence can promote positive health behaviours, which can equips individuals to maintain healthy lifestyles into adulthood.¹ Thus, health services that meet specific and differentiated needs of adolescents are increasingly relevant.² This scoping review is a partnership between a group of mental health researchers interested in investigating how responsive adolescent health services are to youth’s needs in LMIC contexts. We are also interested in identifying behavioural rubrics that define this responsive practice.

To address the increasing need for targeted youth interventions, WHO has outlined several characteristics and components to inform the implementation of targeted adolescent-friendly health services and interventions. In general, under the universal health coverage mandate, it has been recommended that the health services are fundamentally equitable, accessible, acceptable, appropriate and effective. The United Nations Population Fund (UNFPA) established ‘Four Keys’ for guiding the framework for action on adolescents and youth that entails: creating a supportive policy environment; facilitating gender-sensitive, life skills-based sexual and reproductive health (SRH) education; promoting a core package of SRH services; and fostering young people’s leadership and participation. The UNFPA framework aligns with global initiatives such as the International Planned Parenthood Fund (IPPF) and its guidance. IPPF’s definition of youth responsive service is defined as effective youth-oriented service, that is offered with trained providers; it is confidential and non-judgmental.³ Furthermore, adolescent-friendly services should be available during times convenient for and accessible to all youths, such as after school, evenings or weekends. Another key recommendation of this guidance, especially Global Accelerated Action for the Health of Adolescents (WHO AA-HA), is to have services that are acceptable and engage adolescents and youth in behavioural change and health literacy as well as promotion effectively. The services should also have an effective referral system and encourage service users’ and carers’ involvement in the service development and intervention delivery.¹

Additionally, the WHO suggests the following eight global standard activities that ensure high-quality adolescent-friendly interventions: adolescents’ health literacy, community support, appropriate packages of services, providers’ competencies, facility characteristics, equity and non-discrimination, data and quality improvement, and adolescent participation.¹ Further, WHO has issued guidance for member states to carry out the implementation of adolescent programmes used in WHO AA-HA.¹ This guidance includes information for national policy-makers and programme managers when creating and implementing national-level programming aimed at adolescent health.

By comparing our review findings to the existing guidelines and scientific evidence on adolescent-friendly services, we aim to provide a rubric of adolescent-responsive components embedded within interventions within peer-reviewed empirical research studies. We will also compare these to commonly known global guidance on adolescent mental health programming, to address the needs of young people and improve health outcomes. The review will also aim to highlight commonly experienced barriers and facilitators in delivering such interventions in LMICs. As mentioned earlier, we are interested in knowing characteristics, strategies and conditions that were considered part of these services that made these adolescents friendly and those connected to mental or behavioural areas of health treatment, prevention or promotion.

The following research questions were central to this inquiry.

• What are the key components of adolescent-friendly health interventions in LMICs?

• What are the barriers and facilitators of adolescent-friendly health interventions in LMICs?

Materials and methods

Screening

The search strategy to address definitions and exemplars of barriers and facilitators of adolescent-friendly intervention was designed with the help of a research librarian (CM) at the University of Washington. The search was completed on 22nd July 2021 using the following seven databases: CAB Direct, CINAHL, Cochrane Databases, Embase, Global Health Medicus, PsycINFO and PubMed. The search was updated on 15th December 2022 using the same search strategy. The retrieved articles were exported to Zotero referencing software, where duplicate records were deleted before the articles were uploaded to Rayyan.

Title and abstract screening

The prescreening process involved using the WHO age criteria for adolescents, which included studies where participants were 12–24 years old. A study with a broader age range could be included if the participants were divided by age and the mean average age fell within the prespecified WHO age range. The search yielded studies published between January 2000 and November 2022. Only studies published in English were included as all the screeners (CJ, RS and JN) were fluent. The search included studies that involved participants residing in LMICs, as defined by the World Bank. The type of services described in the paper required some amount of meaningful human contact, which the authors defined as an intervention that was either delivered virtually or in person but not cash transfers only. The included studies required active youth involvement and needed youth to be the primary intervention target, so family-based interventions were not included. To attain a variety of adolescent-friendly interventions, studies based on the type of health problem were excluded; instead, a range of health interventions were investigated. The studies needed to include a health problem or related risk/protective factors of a specified health condition.

Full-text screening

During the full-text screening, the inclusion and exclusion criteria expanded on the abstract and title exclusion criteria document. The additional criteria specified that the authors did not restrict based on the study design. Studies that described their intervention as ‘adolescent-friendly’ intervention by outlining features of the intervention that targeted youths were included. As this review aimed to extract descriptive data in narrative form, purely quantitative papers were excluded from the study as they did not include relevant outcomes. Studies required information on the barriers and/or facilitators of delivering an adolescent-friendly intervention in LMICs. The adolescent population included in the study needed to be living in an LMIC, not in a High Income Countries (HIC), as there would likely be significant contextual differences.

Study selection

Each article was double screened during the title, abstract and full-text screening stage. After the screenings, the reviewers discussed the results and resolved discrepancies. The reasons for exclusion were noted for the full-text screening, which can be found in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (see figure 1). Collectively, the reviewers coproduced a data extraction form, which gathered information on each study with a focus on distilling the adolescent-friendly features and identifying barriers and facilitators to the study’s implementation. The data extraction form ensured that similar information was summarised for each article. The PRISMA flow diagram outlines the selection process (see figure 1). A total of 6103 articles were identified. Once duplicates were removed, 4870 articles were included in the title and abstract screening process. This resulted in a further 4699 articles being excluded from the review. The remaining 171 studies were further screened in their full-text form, which removed an additional 165 studies. As a result, 14 articles were included in this systematic review.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. LMICs, low-income and middle-income countries.

Quality appraisal

The quality of each included study was evaluated with the Joanna Briggs Institute (JBI) and Cochrane Risk of Bias 2 (ROB) Tools. We used the specific JBI and ROB 2 tools for the randomised control trials (RCT) and quasi-experimental study designs. The data extraction process was completed before the quality appraisal to allow the reviewers to familiarise themselves with the included studies. All the appraisals were conducted independently by two reviewers. Reviewers discussed the overall quality of each study and resolved discrepancies in the critical appraisal rating through consensus.

Results

Study characteristics

Tables 1 and 2 summarise the characteristics of the 14 studies in the scoping review. The studies were conducted in a range of geographical regions: Africa Region (n=6), South-East Asian Region (n=4), Eastern Mediterranean Region (n=2) and Region of the Americas (n=2). Interestingly, the included studies conducted in the Americas^{4 5} and the Mediterranean^{6 7} investigated interventions aimed at mental health and behavioural problems, while the studies from Africa focused on SRH. The included studies followed either an RCT (n=10) or quasi-experimental (n=4) study design. While most (n=11) of the studies focused on physical health, specifically pertaining to SRH (n=5), four studies addressed mental health topics, including resilience,⁸ psychosocial well-being⁹ and general mental health.¹⁰ Moreover, two studies explored health behaviours, including nutrition⁷ and diabetes.⁴ One study involved education around communicable diseases, specifically hygiene and sanitation.¹¹ The studies varied greatly in the amount of participant information they reported. For example, the sample sizes ranged from 90 participants to 9654 participants; in total, there were data including 23 174 participants in this scoping review. Further, in one study, Flanagan et al did not report the number of participants included in their study; instead, the authors reported the number of clinic visits as 63 183 during the 6-month intervention period. Four of the included reported a mean age for participants.^{4 7 10 12} For the remaining nine studies, the authors either reported the school grade equivalent or the age range of the participants in their study.^{5 6 8 9 11 13–16}

Table 1

Key characteristics of the included studies

Included studies	WHO region	Country	Study design	Targeted health condition	Sample size	Participant’s ages
Hayes et al15	African Region	Tanzania	RCT	Reproductive health and menstruation	9654	14 years and older
Jordans et al9	South-East Asian Region	Nepal	Cluster RCT	Psychosocial well-being	325	to 14 years old
Salum et al5	Region of the Americas	Brazil	Quasi-experimental	Mental health	2457	to 17 years old
Naghaspour et al7	Eastern Mediterranean Region	Iran	RCT	Dietary calcium (nutrition)	188	Average age 14.5 years
Leventhal et al8	South-East Asian Region	India	RCT	Resilience	2732	Not reported
Mathews et al12	African Region	South Africa	Cluster RCT	Sexual health and menstruation	1576	Average age 13.8 years
Tamiru et al11	African Region	Ethiopia	Quasi-experimental	Nutrition	1000	to 19 years old
Rokicki et al16	African Region	Ghana	Cluster RCT	Reproductive health	756	Not reported
Al-Sheyab et al6	Eastern Mediterranean Region	Jordan	RCT	Healthy lifestyle behaviours	791	to 15 years old
Ivanova et al10	African Region	Kenya	Quasi-experimental	HIV	90	to 25 years old
Morales et al4	Region of the Americas	Columbia	RCT	Diabetes and obesity	100	to 19 years old
Mehreen et al14	South East Asian Region	India	Quasi-experimental	STIs	3505	Not reported
Amudhan et al13	South East Asian Region	India	Cluster Randomised Waitlist Controlled Trial	Mental health	400	to 15 years old
Flanagan et al17	African Region	Uganda	RCT	Behavioural intervention for family planning	Not reported	to 19 year old

RCT, randomised control trials; STI, Sexually Transmitted Infections.

Table 2

Characteristics of youth-friendly interventions

Included studies	Theory of change or theoretical background	Setting/s	Delivery agents	Length of training offered to delivery agents	Length of intervention delivered	Meaningful youth engagement, for example, service user involvement
Hayes et al15	Theory of change—curriculum based on social learning theory	Schools, community health units and community proper	Teacher-led, peer-assisted	Not reported	10–15 sessions per year for 3 years	Some peer educators performing short dramas to act as conversation starters and assist with role play
Jordans et al9	Theoretical—assess the efficacy of classroom-based intervention (CBI) among school-going children in rural Nepal	School, classroom	An experienced counsellor provider supervisor to four local research assistants	3 weeks	5 weeks (15 sessions)	None identified
Salum et al5	Theoretical—a collaborative and explorative study to study anxiety disorder	School, classroom	Research assistants, Psychiatry residents, psychiatrists and child and adolescent psychiatrists under the supervision of a senior psychiatrist	2 days	14, 90-min sessions and 12, 90-min sessions over 4 months.	None identified
Naghaspour et al7	Theoretical—study the effects of a nutrition education programme based on the health belief model (HBM) on knowledge, attitude and practice (KAP)	School	Nutrition professionals	Not reported	2 months, 8 sessions	None identified
Leventhal et al8	Theoretical—RCT evaluating a resilience programme	School, classroom	Women from local communities were recruited to serve as programme facilitators	5 days	23 sessions	None identified
Mathews et al12	Theory of change—investigated an after-school sexual and reproductive health education programme for at-risk youth, evaluating barriers and motivators for attendance	School	Trained project staff	Two-week training, weekly supervision and session preparation support	6 months (21 sessions)	During recruitment, a drama student gave talks to each sampled grade 8 class
Tamiru et al11	Theory of change—assessed the effectiveness of school-friendly and peer-led approach in improving personal hygiene practices	School, classroom	Teachers and peer educators	Not reported	8 months	Peer educators
Rokicki et al16	Theoretical—evaluating the effectiveness of a text-messaging education programme for adolescent reproductive health	School	Trained nurse	Not reported	Weekly text message over 3 months	None identified
Al-Sheyab et al6	Theoretical—evaluating the reliability and validity of the Arabic version of Students As Lifestyle Activities (SALSA) survey	School	Peer-led, self-administered by students and facilitated by two research assistants and a volunteer teacher	Not reported	1 session	Peer-led intervention
Ivanova et al10	Theoretical—effectiveness of the peer support platform- ELIMIKA	Hospital however web-based so available in the community	Peer volunteers aged 15–24	Not reported	3 months	Peer volunteers and blog post developers
Morales et al4	Theory of change—intervention integrating social cognitive theory, information–motivation–behavioural skills model and an ecological framework for Colombian Youth	School	Teachers and practitioners	Not reported	5 sessions	Participants suggestions and opinions were integrated into the adaptation process
Mehreen et al14	Theory of change—intervention based on the Health Belief and Social Ecological Models	School, classroom	Peer leaders and teachers	Not reported	5 classroom activities, delivered at monthly intervals	Peer leader
Amudhan et al13	Theory of change—effectiveness of evidence-informed integrated school mental health intervention (SUMS) in promoting mental health knowledge, positive attitudes toward mental illness and behaviours for First Aid in Mental Health among adolescent school children.	Schools	Teachers	3-day workshop	10 sessions delivered over 2 months, 10–15 hours in total	Not reported
Flanagan et al17	Theory of change—intervention is primarily a peer-referral system that advocates for family planning and is intended to reduce stigma about contraceptive use	Clinics	Service providers, trainers, community health mobilisers	3-day standard training	3 months	Peer-referral system

RCT, randomised control trials.

Theory of change and theoretical model

Seven studies adopted a theory of change model, where the authors evaluated an adaptation and modification to a particular intervention, envisioning how it would be delivered and sustained.^{4 11 12 14 15}

Seven of the studies followed a theoretical model, which aimed to explore theoretical rationale or mechanisms underlying the constructs further and evaluated the effectiveness of an intervention keeping those in sight.^{5 7 10 12 14–16} The most common intervention delivery setting was a school (n=10), though two studies were conducted in a clinical setting. Hayes et al conducted their study in multiple settings: schools, community health units and community contexts.¹⁵ Of the studies conducted at schools, four specified that the study was delivered in a classroom^{5 8 9 11}; however, six did not provide specific details on the delivery location^{4 6 7 12 14 16} (see table 2).

Duration and delivery of intervention

Many of the studies (n=8) did not record the duration of training that the delivery agents received.^{4 6 7 10 11 14–16} The remaining studies showed some variance ranging from 2 days to 2 weeks.^{5 8 9 12 13 17} Mathews et al specified that the delivery agents received weekly supervision and support with session preparation after the 2-week training.¹² Furthermore, only Mathews et al indicated that the delivery agents received supervision.¹²

The duration of the intervention delivery ranged from 1 session⁶ to 10–15 sessions per year for 3 years.¹⁵ Most studies reported the number of sessions and the duration in months or weeks. However, five studies only reported the number of sessions or duration of the intervention, such as the number of months or years. The minimal detail made it difficult to establish the comprehensiveness and intensiveness of the intervention.^{4 7 8 10 11} One limitation of the included studies was uneven reporting of the number of sessions, the duration of each session and the length of the entire intervention. It made it challenging to compare resources, time and funding for the implementation of interventions in this setting.

Identification of barriers, facilitators and key components of adolescent-friendly interventions

The included studies highlighted components of their intervention that could be extracted to help develop a theme and consensus around a definition. The studies provided elements of a definition compatible with the guidelines established by the WHO¹ and UNICEF.¹⁸ The peer-reviewed literature did not discuss the parameters presented in the grey literature but did incorporate key elements for adolescent-friendly services.

Components of an adolescent-friendly intervention

Table 3 illustrates how the policy directives from WHO and UNICEF map onto the specific adolescent-friendly interventions included in our review. The authors found that most (n=10) of the interventions met all of the criteria for the WHO Quality Assessment Guidebook. This suggests that most of the studies designed interventions that were equitable, accessible, acceptable, appropriate and effective for adolescents. Specifically, the studies described components of their interventions that meet the WHO guidelines. Hayes et al emphasised the need for local health workers to introduce school services to ensure medical support was ‘welcoming’ and ‘non-judgmental’. Several authors mentioned the importance of considering the specific cultural context. Jordans et al summarised the need for large-scale interventions to account for cultural differences.⁹ Naghashpour et al also emphasised the need for an appropriate intervention to address cultural and traditional habits.⁷ Similarly, Al-Sheyab et al spoke about a programme targeting healthy lifestyle barriers to tailor an intervention effectively.⁶ Further, Mehreen et al’s study described an intervention that relied on two theoretical models to understand the complex interplay of factors that impact adolescent health.¹⁴ Specific to LMICs, the authors highlight the need for rigorous evaluation within resource-constraint, complex emergency settings.⁹ Leventhal et al also expressed a need for greater support of marginalised populations and especially in high-poverty settings to strengthen assets.⁸ Two studies, Mathews et al and Rockiki et al discussed the interventions’ aims of aligning with government policy.^{12 16} Similarly, five studies involved collaborative research processes.^{5 8 10 11 16} Finally, Rockiki et al and Ivanova et al used focus groups with youths to help inform their intervention development seeking adolescent feedback.^{10 16}

Table 3

Assessing the included studies against the key policy framework recommendations

Included studies	Global accelerated action for the health of adolescents (AA-HA!) Guidance to Support Country Implementation	UNICEF Programme guidance for the second decade: Programming with and for adolescents	Clinic assessment of youth-friendly services: a tool for assessing & improving reproductive health services for youth	WHO quality assessment guidebook: A guide to assessing health services for adolescent clients
Hayes et al15	No	Partially (3/4)	Partially (11/12)	Yes
Jordans et al9	Partially (3/6)	No	Partially (7/12)	Yes
Salum et al5	No	No	Partially (6/12)	Yes
Naghashpour et al7	No	Partially (1/4)	Partially (7/12)	Partially (4/5)
Leventhal et al8	Partially (2/6)	Partially (3/4)	Partially (3/12)	Yes
Mathews et al12	Partially (3/6)	Yes	Partially (3/12)	Partially (3/4)
Tamiru et al11	Partially (1/6)	No	Partially (9/12)	Yes
Rokicki et al16	Partially (1/6)	Yes	Partially (6/12)	Partially (4/5)
Al-Sheyab et al6	No	Yes	Partially (11/12)	Yes
Ivanova et al10	Partially (3/6)	No	Partially (10/12)	Yes
Morales et al4	Partially (2/6)	Yes	Partially (9/12)	Yes
Mehreen et al14	Partially (1/6)	No	Partially (9/12)	Yes
Amudhan et al13	Partially (3/6)	No	Partially (10/12)	Partially (4/5)
Flanagan et al17	Partially (4/6)	Partially (2/4)	Partially (11/12)	Yes

Key: green: all features matched, orange: some features matched, red: no features matched.

These ratings were determined through consensus by the authors during their weekly meetings; based on the data extraction from the included studies reporting of their methods/intervention.

Pathfinder International’s Clinical Assessment of Youth-Friendly Services¹⁹ is more specific than the WHO Quality Assessment Guidebook in distilling components of these services.²⁰ It includes the following 12 criteria: location, facility hours, facility environment, staff preparedness, service provided, peer education/counselling programmes, educational activities, youth involvement, supportive policies, administrative procedures, publicity/recruitment and fees.¹⁹ Several of these criteria should have been discussed in the studies, for example, supportive policies, administration procedures and fees, which may be important considerations for the sustainability of an intervention that were missing in our identified studies. However, according to the WHO Quality Assessment Guidebook,²⁰ nearly all studies (n=10) met the criteria.

Similarly, several studies did not meet the WHO AA-HA¹ (n=4) and UNICEF Programmes¹⁸ (n=6) criteria. These policy documents focused on supporting meaningful adolescent involvement, and the level of youth participation varied considerably across the studies. One intervention was as ‘peer-led’, which is an integral component of the WHO AA-HA recommendations for ‘Together’.^{1 6} This recommendation defines ‘Together’ as a youth working for youth.¹ Additionally, a separate study by Ivanova et al included peer volunteers to help facilitate their intervention.¹⁰ The authors emphasise the importance of involving individuals with experiences of living with HIV in developing their online platform, ELIMIKA, which aims to improve adherence to antiretroviral medication.¹⁰ Similarly, Mehreen et al included peer leaders who acted as facilitators for delivering their intervention, and Flanagan et al used peers as an integral part of their referral system.^{14 17} Morales et al highlighted that participants’ feedback was considered and incorporated into the implementation process.⁴ This is similar to Hayes et al that used ‘short dramas’ and ‘role plays’ in delivering their intervention.¹⁵ Mathews et al also included a theatrical component, which intended to lend youth an opportunity to share and communicate their knowledge.¹²

Barriers to conducting adolescent-friendly health intervention studies in LMICs

The limitations of the studies identified fall into two categories: research design and set-up and participation-level barriers (see figure 2 and table 4). The research-level barriers included short study duration^{10 16}; small sample size⁵; small geographical region; limited data collection, non-random allocation¹⁵; and poor reliability of the psychometric instruments.^{5 9} In contrast, the participant-levels outlined were poor literacy levels⁸; COVID-19 restrictions impact social distancing and data collection; familial and personal barriers⁶; limited access to technological resources⁴; little input from students¹¹ and poor attrition due to negative attitudes.¹⁵

Figure 2. Figure to visualise the barriers to studying a youth health intervention in low-income and middle-income countries.

Table 4

Identification of barriers, facilitators and key features of adolescent-friendly interventions

Include studies	WHO region	Features for ‘adolescent-friendly’ intervention	Barriers	Facilitators
Hayes et al15	African Region	Welcoming and non-judgemental attitude and ensuring privacy and confidentiality	Drop-out and loss to follow-up Other responsibilities, for example, extracurricular demands and negative attitudes	Community-based study design
Jordans et al9	South-East Asian Region	Feasible within a resource-poor, complex emergency setting, addressing cultural differences	Internal reliability of instruments Lay screening procedure, may have excluded and underdetected mental health conditions	Situational research
Salum et al5	Region of the Americas	Collaborative explorative project, involving multidisciplinary groups	Small sample size and over-representation of less severe cases Reliable scales	None reported
Naghaspour et al7	Eastern Mediterranean Region	Addressing health conditions caused by social, cultural and traditional stressors	Web-based platform Slow recruitment	Longitudinal follow-up Providing visual stimuli
Leventhal et al8	South-East Asian Region	Weekly facilitated peer-support sessions	Parents' literacy levels	Culturally and contextually sensitive measures Extensive translation and piloting
Mathews et al12	African Region	After-school interventions consistent with the Provincial Government’s policy	Limited geographical representation Parental consent	Participant incentives
Tamiru et al11	African Region	Combination of strategies such as posters, role plays and peer-to-peer discussion	No input from students	Input from researchers and policy-makers
Rokicki et al16	African Region	Unidirectional intervention, an interactive component Ghana Health Service Health Promotion Unit	Short study duration of 12 weeks Multicomponent interventions with self-report measures only	Text messaging programmes
Al-Sheyab et al6	Eastern Mediterranean Region	School-based health intervention addressing relevant barriers	Familial and social barriers	Accessibility to exercise Parental encouragement
Ivanova et al10	African Region	Interactive web-based peer support platform, cocreated with young people	Self-report measures only Short implementation time	eHealth programmes can increase knowledge and perceived importance
Morales et al4	Region of the Americas	Group-based sessions, promoting sexual health in high-risk populations	Limited access to technological resources Restricted funding	Stakeholders' commitment and involvement Cultural values and related issues
Mehreen et al14	South-East Asian Region	Multifactorial intervention, as health behaviours shaped through a complex interplay of determinants	Unevenly distributed sample size Purposive sampling	School environment implementation
Amudhan et al13	South East Asian Region	Classroom-based teacher-led integrated school mental health intervention, promoted positive mental health, mental health literacy and behaviours for First Aid in Mental Health	Limited generalisability and external validity due to small geographical region	Contributes to increased knowledge on positive coping and resilience
Flanagan et al17	African Region	Peer-referral system that formalises word-of-mouth means of advocating for family planning and is intended to reduce stigma about contraceptive use and normalise information-sharing among adolescents.	Social distancing, school closures and other restrictions due to COVID-19 pandemic Limited data collection on family planning counselling in the absence of contraceptive methods	Effectiveness of peer-referral system and youth-friendly training

Facilitators to conducting adolescent health intervention studies in LMICs

The key facilitators included contextual considerations and emphasised meaningful stakeholder involvement (see figure 3 and table 4). Specifically, the facilitators highlighted: conducting community-based studies in rural areas¹⁵; peer involvement; understanding the political and social environment⁵; using a longitudinal study that provides visual aids⁷; culturally adapting information for dissemination; and piloting to ensure that it is meaningful for participants.⁸ The authors mentioned the importance of incorporating input from key stakeholders^{4 11}; ensuring accessibility⁶ such as adopting a text messaging intervention¹⁶; increasing knowledge of the topic⁹; using school-based programmes as teachers can act as role models and schools can become healthier environments for adolescents.¹⁴

Figure 3. Figure to visualise the facilitators of studying an adolescent health intervention in low-income and middle-income countries.

Quality appraisal

The JBI and the Cochrane RoB 2 tools were used to appraise the quality of the studies included in this scoping review (tables 5 and 6 and 8). Of the 14 included studies, 10 were RCT, and 4 were quasi-experimental. The authors selected appropriate outcome measures for the context and samples selected in their studies. Eight included a participant follow-up measure to highlight the long-term effect of their intervention. Nearly all the RCTs and experimental studies (n=7) randomly allocate the participants to treatment groups and control groups. Four of the studies had a low risk of bias, while the other 10 had some concerns. The 10 studies that had some concerns regarding bias did not include information about concealment or discussed interventions in which concealment would not be possible or practical.

Table 5

Johanna Briggs quasi-experimental quality appraisal

Johanna Briggs item	Study reference
	Salum et al5	Tamiru et al11	Ivanova et al10	Mehreen et al14
Is it clear in the study what is the ‘cause’ and what is the ‘effect’?	Yes	Yes	Not Applicable	Yes
Were the participants included in any comparisons similar?	No	Yes	No	Yes
Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?	Unclear	Yes	No	Yes
Was there a control group?	Yes	Yes	No	Yes
Were there multiple measurements of the outcome both pre and post the intervention/exposure?	Yes	Yes	Yes	Yes
Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analysed?	Unclear	No	No	Yes
Were the outcomes of participants included in any comparisons measured in the same way?	Yes	Yes	Unclear	Yes
Were outcomes measured in a reliable way?	Yes	Yes	Unclear	Yes
Was appropriate statistical analysis used?	Yes	Yes	Unclear	Yes
Summary score	6/9	8/9	1/9	9/9

Table 6

Johanna Briggs randomised control trials (RCT) quality appraisal

Johanna Briggs	Study reference
	Hayes et al15	Jordans et al9	Naghaspour et al7	Leventhal et al8	Mathews et al12	Rokicki et al16	Al-Sheyab et al6	Amudhan et al13	Flanagan et al17
Was true randomisation used for assignment of participants to treatment groups?	No	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes
Was allocation to treatment groups concealed?	Unclear	Unclear	Unclear	No	Unclear	No	Yes	No	Unclear
Were treatment groups similar at the baseline?	Yes	Yes	Yes	Yes	yes	Yes	Yes	Yes	Yes
Were participants blind to treatment assignment?	Unclear	Unclear	Unclear	Unclear	Unclear	No	Unclear	Yes	Yes
Were those delivering treatment blind to treatment assignment?	Unclear	Unclear	Unclear	Unclear	Unclear	No	Unclear	No	Unclear
Were outcomes assessors blind to treatment assignment?	Unclear	No	Unclear	Unclear	Unclear	Unclear	Unclear	Yes	Unclear
Were treatment groups treated identically other than the intervention of interest?	Yes	No	Yes	Yes	Yes	Yes	Unclear	Yes	Yes
Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analysed?	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	Yes
Were participants analysed in the groups to which they were randomised?	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes
Were outcomes measured in the same way for treatment groups?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Were outcomes measured in a reliable way?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Was the trial design appropriate, and any deviations from the standard RCT design (individual randomisation, parallel groups) accounted for in the conduct and analysis of the trial?	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	Yes
Summary Score	8/13	8/13	8/13	9/13	9/13	9/13	6/13	11/13	10/13

Table 7

Cochrane risk-of-bias tool

Included studies	Domains of bias
	D1: randomisation process	D2: deviations from the intended interventions	D3: missing outcome data	D4: measurement of the outcome	D5: selection of the reported result	Overall
Rokicki et al16	High risk	Low risk	Low risk	Low risk	Low risk	Low risk
Ivanova et al10	Some concerns	Some concerns	Low risk	Some concerns	Some concerns	Some concerns
Jordans et al9	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Mehreen et al14 .	Some concerns	High risk	Low risk	High risk	Some concerns	Some concerns
Naghashpour et al7	Some concerns	Some concerns	Low risk	Low risk	Low risk	Low risk
Salum et al5	Some concerns	Some concerns	Low risk	Some concerns	Some concerns	Some concerns
Al-Sheyab et al6	Some concerns	Some concerns	Low risk	Some concerns	Some concerns	Some concerns
Hayes et al15	Some concerns	Some concerns	Low risk	Some concerns	High risk	Some concerns
Amudhan et al13	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Tamiru et al11	Some concerns	Some concerns	Low risk	Some concerns	Low risk	Some concerns
Leventhal et al8	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Mathews et al12	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Morales et al4	Some concerns	Some concerns	Low risk	Some concerns	Low risk	Low risk
Flanagan et al17	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk

One quasi-experimental study described a detailed follow-up process and analysed the data appropriately, and all the quasi-experimental designs included multiple outcome measures. Both the RCTs and quasi-experimental studies lacked the concealment of participants, delivery agents and outcome assessors which could impact the validity and reliability of the results. The RoB tool found that all 14 studies had a low risk of being biased by missing outcomes.

The consistent absence of concealment suggests a need to improve measures to counteract potential bias at all stages of the research process. Moreover, quasi-experiment studies included multiple outcomes of the interventions and provided robust information, which enabled a better understanding of the impact of the interventions. Additionally, the loss to follow-up may suggest attrition bias.

Discussion

The included peer-reviewed studies incorporated key elements of adolescent-friendly interventions in line with the WHO¹ and UNICEF¹⁸ standards (see figure 4 and table 8). Although not all the key recommendations were described in each included study, every paper discussed at least one key element from the WHO¹ or UNICEF¹⁸ guidelines. One of the key elements extracted from the studies included a non-judgmental approach with an emphasis on privacy and confidentiality.^{15 21} Additionally, interventions that were responsive and considerate of cultural differences were preferred.^{7 9} This aligns with findings from previous reviews that identify confidential and culturally responsive care as an important consideration for adolescent-friendly services.^22–25 For a service to be sustainable, it may require collaboration with local and national governments, as demonstrated by both Mathews et al and Rockiki et al.^{11 14} Peer support was also identified as a feature that augments youth’s experiences, specifically those living in high-poverty settings.⁸ The importance of peer involvement in development aligns with the frameworks discussed and the findings of other reviews.^26–28 However, across the included studies, limited peer involvement was observed in the intervention design and delivery, despite the involvement of youth being considered an important element in nearly all the frameworks discussed in this review.^{22 29} Although this appears to be a gap in the studies included in our review, we believe that the engagement of adolescents is critical in developing equitable policies programmes, and service systems, including evolving a framework and codesign for peer-to-peer support and facilitating youth-led interventions.

Figure 4. Network comparison of included studies and policy recommendations. The diagram illustrates how the included studies met the criteria outlined in the policy documents: Global Accelerated Action for the Health of Adolescents (WHO AA-HA), WHO Quality Assessment, UNICEF Second Decade and Path Finder Clinic Assessment. If all the criteria were met, we noted this relationship with a green line if all the criteria were met. If some criteria were met, we illustrated the relationship with a yellow line. As seen in the diagram, the WHO Quality Assessment and UNICEF Second Decade were most compatible with the included studies.

Table 8

Key recommendations from the policy guidelines

Name of framework	Key recommendations
WHO Global Accelerated Action for the Health of Adolescents (AA-HA!) Guidance to Support Country Implementation Support Country Implementation	“Approach: A systematic approach for health span across generations understanding adolescent health needs, prioritizing these in the country context and planning, monitoring and evaluating adolescent health programmes.” “Prevention: Although much research is still needed, effective interventions are available for countries to ACT NOW.” “Priority-Setting: Governments should prioritize their actions according to the disease and injury risk factor profiles of their adolescent population as well as the cost-effectiveness of the interventions. Adolescent health needs intensify in humanitarian and fragile settings.” “Leadership: Strong leadership at the highest level of government should foster implementation of adolescent-responsive policies and programmes.” “Yields from investing in adolescent health span across generations: There is a pressing need for increased investment in adolescent health programmes, to improve adolescent health and survival in the short term, for their future health as adults and for the next generation.” “Together: National development policies, programmes and plans should be informed by adolescents’ particular health-related needs and the best way to achieve this is to develop and implement these programmes with adolescents.”
UNICEF Programme Guidance for the Second Decade: Programming with and for Adolescents	“Adopt a positive development approach: which considers adolescent girls and boys as assets and seeks to empower them to participate actively within their families and communities.” “Use a rights-based, gender-responsive equity approach: Rights should apply equally to all adolescents, irrespective of age, gender, civil status, geography, wealth, ethnicity, religion, immigration status or disability. A key dimension of an equity approach, which addresses the root causes of inequities, is gender equality, which means that girls and boys equally enjoy the same rights, resources, opportunities and protections.” “Apply a life course approach: to build a continuum of support and maximize investment across two decades of a child’s life—evidence has shown that using a life course approach allows for a better use of scarce resources by identifying critical risks and gaps across childhood and prioritizing key interventions to help break cycles of poverty.” “Support meaningful and systematic participation of adolescent girls and boys: For participation to be meaningful across all sectors, adolescents require access to safe spaces, the ability to voice their views, opportunities to exert their influence and a receptive audience in order to consult on and contribute to leading the interventions they choose to take part in.”
Pathfinder Clinic Assessment of Youth-friendly Services: A tool for assessing & improving reproductive health services for youth	“Location: When establishing a location for new operations, consider young people’s desire to outside for privacy among their neighbourhood, while also considering the travel limitations young people experience. The locations should be in a safe environment and, ideally, should be accessible by public transportation.” “Facility Hours: Having clinics open at times when young people can conveniently attend is fundamental to effective recruitment and service provision. Such times typically include late afternoons (after school or work), evenings, and weekends.” “Facility Environment: The service environment should be comfortable, private, and have posters or décor relatable to the young people. To reduce the feeling of being overly sanitized, providers might opt to wear “street clothes”. Creating separate space and special hours for adolescents also appears to be important for some clients.” “Staff Preparedness: Having a specialized staff that is trained to work competently and sensitively with young people is often considered the single most important condition for establishing youth-friendly services.” “Services Provided The more health needs of young people that can be met within the facility or program, the greater assurance that adolescents will receive the care they need.” “Peer Education/Counselling Program It is productive, to have peer educators or counsellors available as alternatives or supplements to some aspects of the counselling activities, as evidence shows that many young people prefer talking with their peers about certain sensitive issues.” “Educational Activities: Peer counselling or educational computer-based education during the waiting period prior to seeing a provider can be useful, to reach a wider range of young people. Incorporating a peer component helps adolescents realize their fears are not unique. Adding smaller branches and interactive online resources can also be useful.” “Youth Involvement: A fundamental principle in design of youth-friendly services is to ensure participation of young people in identifying their needs and preferences for meeting those needs.” “Supportive Policies: Given that reproductive health projects for young adults are new, operational policies governing how providers should serve this group are evolving and not always clearly spelled out. Staff should have clear legal guidelines, with operational policies detailing the full extent of services allowable under the law. “Administrative Procedures: Because adolescents are present-minded and rarely plan ahead, the possibility of receiving services without an appointment can increase adolescent access. Providers should plan to spend more time in adolescent than adult appointments.” “Publicity/Recruitment: Recruitment is often best handled by young people themselves, both formally (such as distributing printed information or making presentations) and informally (by word of mouth). Young people can reassure one another that they are welcome and will be served respectfully and confidentially.” “Fees A fee schedule must be designed so that services are free or affordable. They can be established on a sliding scale, possibly including credit and flexible payment options.”
WHO Quality Assessment Guidebook: A guide to assessing health services for adolescent clients	“Equitable: All adolescents, not just certain groups, are able to obtain the health services they need.” “Accessible: Adolescents are able to obtain the services that are provided.” “Acceptable: Health services are provided in ways that meet the expectations of adolescent clients.” “Appropriate: The health services that adolescents need are provided.” “Effective: The right health services are provided in the right way and make a positive contribution to the health of adolescents.”

One example of a country-level stance on youth engagement is from the UK’s National Health Service England which has outlined ‘key principles for effective peer support’. These include shared experience; accessible and inclusive; recognising strengths, values, needs and feelings of the individual; safe and authentic space; reciprocal relationship; support to find solutions, flexible and adaptive; and encouraging accessing to clinical advice and ensuring the person receives the right kind of support.³⁰ Organisations in LMICSs that embody these principles include the Naguru Teenage Information and Health Centre in Kampala, Uganda which trains peer health educators to connect with their peers through a call-in radio programme and Ogun State Adolescent Sexual and Reproductive Health Technical Working Group, through which youth representatives participate in the planning and implementation of ASRH-related policies, programmes and activities.³¹

Moreover, meaningful engagement of adolescents is a critical component of WHO AA-HA principles and guidelines, which did not appear to be found in the included studies. Other reviews evaluating adolescent-friendly services determined that adolescent involvement in the development, delivery and evaluation is important in improving the acceptability of interventions targeted at youth, challenging social and cultural norms and promoting behaviours associated with help-seeking.^{22 29 32}

The elements extracted from the included studies contained the following WHO principles—focus on prevention and treatment.³³ This definition also confers with the WHO-AA-HA guidelines of confidentiality/non-judgmental, training of providers and accessibility, which includes community or school-based intervention. Although all four of these guidelines refer to the state and national levels of public health planning, the authors saw the benefit of including specific guidelines for individual community-level interventions. The noted discrepancy in the number of young people enrolled in schools in LMICs limits the reach of these interventions.³⁴ This may advocate for expanding adolescent-friendly services in settings beyond the classroom, to communities and spaces where adolescents are likely studying, working or generally found. Out-of-school adolescents are one neglected, vulnerable population that would need more tailored community-based intervention.³⁵

Additionally, we found that the studies varied in their structures for adolescent engagement, for example, the duration and number of sessions; we were unable to draw conclusions about the quality of these interventions. However, an important consideration of working in LMICs, and in mental health in general, is the resource constraints, which advocate for task-sharing approaches. A previous review identified both intersectoral collaboration and task-sharing approaches as facilitators of youth-friendly services LMICs.³⁶ Further, the feasibility and practicality of implementing a service might highlight trade-offs, that is, the barriers identified in our review, for example, short study duration,^{10 16} poor reliability of the psychometric instruments,^{5 9} poor literacy levels⁸ and familial and personal barriers.⁶ Thus, future researchers may need to adapt to their setting to ensure the sustainability of their interventions.

Moreover, our review identified the barriers and facilitators to service delivery and interventions in LMICs. The key facilitators included contextual considerations (ie, political and social environment) emphasised meaningful stakeholder involvement and made information culturally adapted. These facilitators emphasise the need to understand the context and involve key stakeholders from the project’s onset. To ensure a sustainable youth-responsive intervention, future researchers must use a dual approach combining bottom-up and top-down approaches to support the targeted health concerns.

The authors conclude that additional research is needed to evaluate strategies to support the scale-up and sustainability of adolescent-friendly interventions in resource-constrained settings. Previous literature has outlined the following challenges to implementing adolescent-friendly services in LMICs, including training, infrastructure, service user involvement, evaluation strategies and support for healthcare providers.²⁶ These considerations resonate with the findings of our scoping review, as several studies also reported the short research duration of the intervention.^{5 7 9–12 16} It would be critical for future research to explore ways key stakeholders, including service users, could be involved in the research process, from proposal drafting to implementation.

The WHO’s AA-HA outlines guiding priorities for adolescent health on the level of national policy-making.¹ The development of a tool based on the core components outlined in this review to create a standardised baseline of requirements for adolescent-friendly care could be a reasonable next step to parse further which additional features are barriers and facilitators for adolescent-friendly care. Figure 5 presents some guidance on development of a tool keeping our review and policy guidelines in mind. The attributes of ‘together’ with and for adolescents, through relevant contextual ‘priority setting’ and ‘leadership’ driven processes can enable a system that can transform adolescent health across generations to blend into population health. Figure 5 also provides pointers to a checklist that this tool must cover in terms of cross-sectoral domains of adolescent health programming. While such a standard would necessitate the consideration of geographical and service-type specific factors, it could act as a starting point for defining positive and negative features of care.

Figure 5. Key attributes and guidance for a possible tool assessing adolescent-friendly services and/or intervention development.

Limitations

Possible limitations of this review include an absence of information extracted from grey literature and frameworks that were not formally published and publicly available on this theme. This may have resulted in missing features of adolescent interventions. Conversely, the reporting of the methodology appeared to have influenced the quality of the studies and the detail of data available.

Conclusion

This scoping review attempted to identify an operational definition for an ‘adolescent-friendly’ intervention. To synthesise the literature to an operational definition, we created a rubric based on the similarities across studies. The included studies contained key features of adolescent-friendly interventions; these components included fostering a welcoming and non-judgmental environment, providing culturally appropriate and responsive services, and focused support for marginalised communities within high-poverty settings.^{4–12 15 16} Furthermore, the included studies did not detail the barriers and facilitators of developing or implementing their intervention; instead, they appeared to focus on the strengths and weaknesses of their study. The implementation of the interventions including youth-friendly services needs to become a guiding principle to evaluate acceptability, effectiveness and sustainment of interventions.

MK would like to acknowledge the support of Dr Ogedegbe and IEHE towards publication of this paper.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. This is a review and all data have been presented in the paper.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.

Footnote

Handling editor Helen J Surana

X @manasikumar229

Contributors MK conceptualised the review. KV-C, CJ, RS, JN and MK designed the detailed search strategy with support from CMa and AM. CJ, RS and MK developed the first draft and subsequently all authors including CMo and SP reviewed and edited the final review. All authors read, commented and agreed with the final version. CJ and RS act as guarantor and MK is responsible for the overall content of the review.

Funding RS’ work on the review was funded by the Mary Gates Endowment at the University of Washington. MK was supported by NIMH/FIC R33MH124149-03 and K43TW010716-05.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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