Prevalence and barriers to the utilization of adolescent and youth-friendly health services in Ghana: systematic review and meta-analysis | Reproductive Health

Summary of findings

This systematic review of AYFHS utilisation in Ghana reveals a complex landscape of factors influencing adolescents and youths’access to these critical services. The pooled prevalence of AYFHS utilisation is approximately 42%, highlighting room for improvement in ensuring that these services effectively reach the target population. Personal factors, such as gender, religious beliefs, education, and financial constraints, significantly shape utilisation patterns. Family-related factors, including the role of parental support and attitudes, further impact adolescents’access to AYFHS. Facility-related challenges, like shortages of medicines and long waiting times, and service provider-related factors, such as negative attitudes and lack of confidentiality, pose additional barriers. Furthermore, community and societal norms, influenced by cultural, religious, and educational factors, play a substantial role in shaping adolescents’and youths’decisions regarding AYFHS utilization.

Prevalence of utilisation of AYFHS

The findings of this systematic review indicate that only 42% of adolescents in Ghana utilize adolescent and youth-friendly health services (AYFHS), signaling that while progress has been made in increasing access, a significant proportion of young people still face barriers to service utilization. AYFHS is a critical component of adolescent healthcare, offering essential support for sexual and reproductive health, mental health, and general well-being. The reported utilization rate aligns closely with findings from Ethiopia (42.73%) [19], suggesting that similar structural and socio-cultural factors may be shaping adolescent health service engagement across sub-Saharan Africa. However, this consistency also highlights a broader issue—persistent gaps in service availability, accessibility, and acceptability that hinder effective adolescent health service delivery.

A deeper examination of these utilization patterns reveals that despite efforts to establish youth-friendly health initiatives, many adolescents remain underserved due to barriers at multiple levels. Structural and facility-related constraints such as long waiting times, inadequate privacy, and shortages of adolescent-trained health professionals contribute to service underutilization. Additionally, societal and cultural norms that stigmatize adolescent access to sexual and reproductive health services further discourage young people from seeking care. These challenges reinforce the need for tailored interventions that address the complex interplay of personal, familial, community, and systemic factors limiting AYFHS uptake.

The substantial heterogeneity identified in the included studies suggests that AYFHS utilization varies significantly across different geographical and socio-economic contexts in Ghana [2]. This variation underscores the importance of localized health policies that cater to the unique needs of adolescents in diverse settings. Rural adolescents, for instance, may face compounded barriers, including distance to facilities and lower levels of awareness, while urban youth may experience confidentiality concerns or judgmental attitudes from providers. By applying a random-effects model, this review accounts for such variability, enhancing the reliability of the prevalence estimate. Moreover, the absence of publication bias, confirmed by Egger’s regression test, strengthens confidence in the findings by reducing concerns about selective reporting of positive outcomes.

The implications of these findings extend beyond individual health outcomes, linking directly to global development targets. AYFHS utilization plays a crucial role in achieving Sustainable Development Goal (SDG) 3 (Good Health and Well-being) by ensuring that adolescents have access to the preventive and curative services they need [9]. Additionally, given that gender-based barriers disproportionately affect adolescent girls, improving AYFHS aligns with SDG 5 (Gender Equality), empowering young women to take control of their health and reproductive choices [27]. Furthermore, comprehensive adolescent health education provided through these services contributes to SDG 4 (Quality Education), as well-informed adolescents are more likely to make safe and responsible health decisions that enhance their academic and personal development [8]

To bridge the utilization gap, urgent policy action is needed to integrate AYFHS more effectively into mainstream healthcare services. Expanding youth participation in the design and implementation of adolescent health programs can ensure that services are more responsive to the needs of young people. Additionally, addressing provider-related barriers through targeted training programs can enhance the quality of care, making health facilities more welcoming and non-judgmental for adolescents. Community-based interventions that engage parents, religious leaders, and educators are also critical in shifting societal perceptions and fostering an enabling environment for AYFHS utilization. Without strategic investments and coordinated efforts, the promise of youth-friendly health services will remain unrealized, limiting progress toward adolescent health and well-being in Ghana.

Personal and Family barriers to the utilization of AYFHS

The findings of this review emphasize that personal factors such as gender, education, religion and financial constraints significantly impact adolescents’ utilization of Adolescent and Youth-Friendly Health Services (AYFHS) in Ghana. For instance, the study identifies gender as a critical determinant, with female adolescents facing unique barriers influenced by societal norms and expectations. These findings align with Adokiya et al. [5] and Amoadu et al. [8], who argue that conservative cultural settings often hinder young females from accessing sexual and reproductive health services. However, in contrast, a study conducted in Kenya by Nyblade et al. [37] reports a more equitable utilization pattern, attributed to targeted gender-inclusive interventions and campaigns. This disparity may reflect differences in policy prioritization and cultural settings, highlighting the need for Ghana to adopt similar gender-sensitive strategies. Religious beliefs, particularly within the Muslim context, can either encourage or discourage AYFHS utilization. Depending on the interpretation of religious teachings, some adolescents may feel compelled to seek sexual and reproductive health services, while others may abstain due to religious doctrines promoting abstinence before marriage [5, 8].

Education, or the lack thereof, significantly impacts adolescents’access to AYFHS. For instance, limited education often results in lower health literacy, affecting adolescents’ability to make informed decisions about their sexual and reproductive health [2, 32]. This education gap can perpetuate misconceptions and limit adolescents’understanding of available services, potentially deterring them from seeking AYFHS.

The review also reveals financial constraints as a significant barrier, particularly for economically disadvantaged adolescents. Adolescents from economically disadvantaged backgrounds may struggle to afford necessary services and contraceptives, making access to AYFHS a financial burden [2, 23]. These findings contrast with reports from South Africa [35], where government subsidies and free services mitigate financial challenges. The differences may stem from Ghana’s limited resource allocation for adolescent health services, suggesting that policies such as subsidized or free AYFHS could enhance accessibility for low-income populations.

Family-related factors, on the other hand, underscore the critical role of parental support and attitudes. Parental support can be a strong motivating factor for adolescents to seek AYFHS [2, 7]. Supportive parents are more likely to encourage open conversations about sexual health and facilitate access to services [2]. Conversely, negative parental attitudes and the requirement for parental or guardian consent can act as substantial deterrents. Parents often hold considerable sway over adolescents’decisions, so fostering a supportive and understanding family environment is crucial for improving AYFHS utilization among young individuals.

These findings carry practical implications for healthcare policies and interventions in Ghana. Recognizing and addressing these personal and family-related factors is essential. Culturally sensitive and gender-inclusive approaches are imperative for bridging gender disparities in AYFHS utilization. Targeted educational campaigns should aim to improve health literacy and raise awareness among adolescents and their families about the importance of AYFHS. Reducing financial barriers through subsidized or free services can make AYFHS more accessible to economically disadvantaged youth. By acknowledging and addressing these multifaceted factors, Ghana can make significant strides toward achieving Sustainable Development Goals related to sexual and reproductive health and overall well-being.

Facility and healthcare-related provider-related barriers to the utilization of AYFHS

Shortages of essential medicines and supplies within healthcare facilities have been identified as significant barriers to the utilization of Adolescent and Youth-Friendly Health Services (AYFHS) in Ghana. Adolescents often expect healthcare facilities to meet their medical needs, and when this expectation is unmet, it can lead to dissatisfaction and a reluctance to seek future care [2]. This finding aligns with studies from other low- and middle-income countries (LMICs), such as Ethiopia and Kenya, where similar challenges have been reported [21, 26]. In Kenya, for instance, inadequate stock of essential contraceptives and medicines was a significant deterrent for adolescents seeking sexual and reproductive health services, mirroring the frustrations reported in the Ghanaian context.

Long waiting times and inconvenient operating hours also discourage AYFHS utilization. Adolescents often juggle multiple responsibilities, including school and work, making accessibility and convenience critical factors in their healthcare-seeking behavior [2]. Similar findings have been observed in Malawi, where adolescents cited inflexible operating hours as a key barrier to accessing healthcare [38]. However, some interventions, such as extending facility hours or offering school-based health services, have shown promise in improving accessibility in other settings [30]. Ghana could benefit from adopting such strategies to enhance service availability and utilization.

Provider-related factors, such as negative attitudes and breaches of confidentiality, further exacerbate barriers to AYFHS utilization. Adolescents who experience judgmental or dismissive behavior from healthcare providers often feel unwelcome and avoid seeking care [8, 21]. Studies from Nigeria and Uganda similarly highlight how provider attitudes can undermine trust and discourage adolescents from accessing services [17, 36]. In contrast, countries that prioritize training for healthcare providers in adolescent-friendly communication and nonjudgmental care, such as Rwanda, have reported improved client satisfaction and service uptake [20]. Ghana’s healthcare system could benefit from implementing similar training programs to ensure that providers deliver empathetic, respectful, and confidential care.

Addressing these facility and provider-related barriers is critical for improving AYFHS utilization in Ghana. Key steps forward include ensuring consistent availability of essential medicines, optimizing facility operating hours, and providing comprehensive training for healthcare providers. By drawing lessons from other LMICs and tailoring these interventions to the Ghanaian context, the country can create a more inclusive and supportive environment for adolescents. Such efforts could lead to enhanced AYFHS utilization, ultimately promoting better sexual and reproductive health outcomes among young people in Ghana.

Community and societal-related barriers to the utilization of AYHFS

Community and societal norms play a pivotal role in shaping adolescents’and youths’decisions regarding the utilization of Adolescent and Youth-Friendly Health Services (AYFHS) in Ghana. Cultural, religious, and educational factors heavily influence their behaviors and attitudes [7, 21]. Traditional customs and values often stigmatize discussions about sexual health, causing shame or reluctance to access services [8, 33]. This cultural hesitation aligns with findings from studies in Nigeria and Kenya, where similar stigmatization has been observed, often preventing open dialogues about sexual health and perpetuating myths about AYFHS [17, 26]. However, in countries like Rwanda, cultural barriers have been mitigated through culturally sensitive outreach programs, highlighting the potential of culturally tailored interventions to improve service utilization [20].

Religious doctrines emphasizing abstinence and condemning premarital sex further restrict adolescents’access to sexual and reproductive health services. For example, in Ghana, religious beliefs often associate the use of contraception with promiscuity, discouraging its uptake [3, 8]. This aligns with studies in Malawi and Uganda, where religious teachings similarly dissuade adolescents from seeking reproductive health services [36, 38]. However, contrasting evidence from Ethiopia suggests that collaborative efforts between religious leaders and health practitioners can reduce these barriers by integrating health messages with religious teachings [30].

The lack of comprehensive sex education compounds these challenges, leaving adolescents uninformed about their sexual and reproductive health rights and options [2, 3]. This gap mirrors findings from Zambia and Tanzania, where limited education perpetuates misinformation about AYFHS [21]. By contrast, countries like South Africa, which have implemented school-based comprehensive sex education programs, report higher levels of adolescent awareness and improved health outcomes [40].

To overcome these community and societal barriers, Ghana must adopt multi-pronged strategies. Comprehensive sex education programs tailored to cultural and religious contexts can provide factual information while respecting traditional values. Community engagement and awareness campaigns should foster open discussions about sexual health, addressing stigma and misconceptions. Lessons from Ethiopia and South Africa suggest that involving community and religious leaders in these initiatives can further promote acceptance and utilization of AYFHS. By addressing these barriers, Ghana can create a supportive environment that encourages adolescents and youth to access AYFHS, ultimately improving their sexual and reproductive health outcomes.

Limitations in this review and recommendation for future studies

This review focused on only qualitative and cross-sectional studies which might reduce the volume of included studies. Furthermore, the authors focused on only studies published in the past decade. This situation might further reduce the volume of papers included in this review. Reviewed studies were from only three out of the 16 administrative regions in Ghana. This situation may compromise the generalisation of the review findings to entire adolescent groups in Ghana. It is also noteworthy that, using only the meta-analysis was based on findings from cross-sectional surveys which are relatively compromised by bias response due to self-response measures. However, the authors appraised all included studies using well-established tools. The authors also ensured robustness through thorough search, screening, data appraisal, and extraction process which may contribute to enriching the evidence from this synthesis. Improved study designs such as randomised controlled trials, and cohort and longitudinal designs are encouraged for future studies and synthesis. Also, cross-sectional survey researchers are encouraged to use more validated measures. Moreover, studies utilizing national representatives of adolescent samples from both in-school and out-school should be encouraged.