Search outcome
Of the 7413 records identified, 6290 were screened based on title and abstract. Of these, full text of 144 studies were further screened. Thirteen (13) studies were deemed to meet the inclusion criteria. No studies were excluded following assessment of methodological quality (Fig. 1).
Characteristics of the included studies
The characteristics of the included studies are summarized in Table 1. Studies included in the review consisted of eight qualititative studies [32, 36-39, 42-44], four quantitative studies [34, 35, 40, 41] and one mixed methods study [33]. Of the quantitative studies, two studies were quasi-experimental studies without a comparison group [34, 35], one study was a quasi-experimental study with a comparison group [40], and one study was a randomised controlled trial [41].
Included studies were published between 2010 and 2020, with six studies [34, 38, 41-44] published in 2012.
Seven countries were represented across the included studies including the United States of America [34, 35, 37, 40-42], Tanzania [43, 44], Yemen [32], Myanmar [33], South Africa [36], Uganda [38] and Mozambique [39].
In terms of setting, seven studies were conducted in community settings [32, 34-37, 39, 43], two studies were undertaken in educational settings [38, 40], two studies were conducted in healthcare settings [41, 42], one study was undertaken in community and healthcare setting [33], and one study was conducted in community, educational and healthcare setting [44].
Participants were youth or intervention receipients in eight studies [34-38, 41-43]. One study included youth and implementers [33], one study involved youth, implementers and community members [32], one study included youth, family members and community members [39], one study incorporated youth and community members [44], and one study included implementers [40]. The number of participants within the included studies ranged from two to 343. Rorhbach, 2019 [40] did not report the number of implementers (trained program staff).
Overall, the quality of the included studies was good with nine studies [32, 34, 35, 39-44] scoring more than 70% on quality appraisal tool. Four studies [33, 36-38] were rated as fair (scored between 50% and 70% on quality appraisal tool) [Supplementary File 1, Tables 2-4].
Barriers and facilitators
Thematic synthesis [30, 31] and mapping of the study findings to the Determinant Framework [17] highlighted a wide range of barriers and facilitators to HIV prevention interventions for reducing risky sexual behavior among youth. A summary of the identified barriers and facilitators across the five Determinant Framework domains is presented in Table 2.
Barriers to HIV prevention interventions for reducing risky sexual behavior among youth
A total of 79 barriers to HIV prevention interventions for reducing risky sexual behavior among youth were identified from the included studies: 42 in the characteristics of the context, 21 in the characteristics of the end users, seven in the characteristics of the implementation object, five in the characteristics of the strategy of facilitating implementation and four in the characteristics of the users domains.
Characteristics of the context
Barriers within the characteristics of the context domain were reported by 11 studies [32-34, 36-39, 41-44]. Four types barriers emerged: interpersonal, community, organizational or institutional and structural barriers.
The most common interpersonal barriers identified involved those linked to reduction of risky sexual behavior among youth. These included partner’s refusal of HIV prevention methods (e.g., condom use) [32, 33, 38, 39, 42], negative peer influence [38, 43, 44], lack of financial support from family [38, 39, 43], partner’s desire for pregnancy [42] and lack of child-parent communication on sexual issues [36, 38]. Additional interpersonal barrier reported included lack of support for critical thinking among young people [44].
Community barriers that occurred more prominently involved those associated with reduction of risky sexual behavior among youth. These included gender-biased norms [36-39, 43, 44], norms discouraging open communication on sexual issues, myths about contraceptive [32, 44], limited resources or services in the community (e.g., programs targeting young people) [32, 33], cultural beliefs and norms encouraging risky sexual behaviors [44]. Another common set of community barriers identified consisted of those associated with young people’s participation in the intervention, such as incarceration and community violence [34].
Reported organizational barriers included lack of financial and human resources, inaccessibility of healthcare facilities, limited confidentiality and restrictions on depicting of condoms in schools [44]. Other type of organizational barriers identified involved those linked to reduction of risky sexual behavior among youth, and these included lack of resources (e.g., personnel); inaccessibility of services (e.g., condoms) and limited confidentiality [44]. Additional organizational barriers reported comprised of those associated with youth’s participation in the intervention. This included inaccessibility of intervention venue [34, 37].
The most common set of structural barriers reported involved those correlated with reduction of risky behavior among young people, such as gender-based violence [39, 41], unemployment [32] and limited economic opportunities [44]. Additionally, poverty, limited demand and cost of services (e.g., condoms) [44] were identified as structural barriers.
Characteristics of the end users
Seven studies [32, 33, 38, 41-44] identified barriers at the level of characteristics of the end users. Barriers that appeared more prominently included those associated with reduction of risky sexual behavior among youth. Such barriers included lack of self-confidence [42], desire for pregnancy or children [42, 43], low perceptions of risk of sexually transmitted infections including HIV [38, 42-44], fear of relationship breakdown [33, 38, 42, 43] and poor decision-making skills [42, 44]. Other common set of barriers consisted of those related to young people’s participation in the intervention, such as concern for privacy [32] and fear of stigma [44]. Further barriers reported included being uncooperative, having low literacy and having limited sexual health knowledge [44].
Characteristics of the implementation object
Five studies [33-35, 43, 44] mentioned barriers within the domain of the characteristics of the implementation object. The most common set of barriers identified involved those associated with intervention acceptability among young people. Such barriers included incompatibility of intervention content with the needs of youth [33-35, 43], long duration of the intervention [33, 35] and complexity of the intervention [35]. Additionally, barriers reported concerned those linked to youth’s participation in the intervention, such as restricted days and times of the intervention [34] and age requirements that excluded other youth [33]. Additional barriers that emerged included those associated with reduction of risky sexual behavior among young people. This included limited intervention content [44]. Incompatibility of intervention content with needs of community members [44] was identified as a barrier to intervention acceptability among community members.
Characteristics of the strategy of facilitating implementation
Two studies [32, 44] mentioned barriers within the characteristics of the strategy of facilitating implementation domain. Barriers reported included failure to implement the intervention with fidelity, use of non-participatory facilitating or teaching methods, use of corporal punishment and sexual abuse [44]. Another category of barriers identified involved those associated intervention acceptability among youth. This included use of non-participatory facilitating methods [32].
Characteristics of the users
At the level of characteristics of the users, barriers were reported by two studies [37, 44]. Identified barriers included implementers’ lack of knowledge related to content of the intervention, poor education or training of implementers and implementers’ lack of exemplary or positive behavior [44]. Adult or older implementers [37] was mentioned as a barrier to intervention acceptability among young people.
Facilitators to HIV prevention interventions for reducing risky sexual behavior among youth
There were 53 facilitators to HIV prevention interventions for reducing risky sexual behavior among youth identified from the included studies: 15 in the characteristics of the end users, 15 in the characteristics of the context, 14 in the characteristics of the strategy of facilitating implementation, five in the characteristics of the implementation object and four in the characteristics of the users domains
Characteristics of the end users
Facilitators within the characteristics of the end users domain were reported in seven studies [32, 36, 37, 39, 42-44]. Facilitators that emerged more prominently consisted of those related to reduction of risky sexual behavior among youth. Such facilitators included fear of pregnancy and sexually transmitted infections including HIV [32, 37, 43], having strong ambitions or being future-oriented [39, 44], having good problem-solving skills, having high self-confidence, being knowledgeable [42], having high self-motivation [39] and low socio-economic status (e.g., lack of money to pay for sex) [44]. Other group of facilitators identified comprised of those associated with young people’s participation in the intervention. These included desire to acquire knowledge and need for enjoyment [37].
Characteristics of the context
Six studies [33, 38, 39, 42-44] identified facilitators at the characteristics of the context level. Three classifications of facilitators occurred: interpersonal, community and organizational facilitators.
The most common interpersonal facilitators reported involved those associated with reduction of risky sexual behavior among youth. These included partner’s consent to use an HIV prevention method (e.g., condom use) [42, 43], positive peer influence, restrictive parenting [38, 44], financial support from family [39, 43] and teacher advice [38].
Similarly, community facilitators that emerged more prominently comprised of those linked to reduction of risky sexual behavior among young people. Such facilitators included norms encouraging healthy sexual practices (e.g., abstinence and delaying of sexual debut) [38, 44], norms encouraging discussion of sexual issues [44] and religious beliefs discouraging risky sexual behaviors [38].
Organizational facilitators reported involved those associated with intervention acceptability among youth, and this included accessibility and friendliness of intervention venue [33].
Characteristics of the strategy of facilitating implementation
Facilitators within the characteristics of the strategy of facilitating implementation domain were mentioned by six studies [32, 35-37, 40, 44]. These included implementation of intervention with fidelity [40, 44], dissemination of intervention information to community members [32, 36, 37], use of participatory facilitating methods, decreased corporal punishment [44] and collaboration among different stakeholders in delivering the intervention [32]. Another category of facilitators identified consisted of those correlated with young people’s involvement in the intervention. Such facilitators included provision of incentives [32, 37], building of a trusting relationship with young people, mobilization of community members to influence youth to attend the intervention, integration of intervention with other services and use of same age or peer implementers [32]. Further facilitators reported involved those linked to intervention acceptability among youth, such as use of same sex youth group [35, 36] and use of different or mixed facilitating methods [35].
Characteristics of the implementation object
Facilitators within the characteristics of the implementation object domain were identified by four studies [32, 35-37]. Two groups of facilitators emerged: those associated with intervention acceptability among youth and those associated with intervention acceptability among implementers. Identified facilitators to intervention acceptability among youth included compatibility of intervention content with the needs of youth [35-37], same sex youth group [36, 37] and detailed or comprehensive intervention content [37]. Compatibility of intervention content with the needs of youth and relative advantage of the intervention [32] were reported as facilitators to intervention acceptability among implementers.
Characteristics of the users
Four studies [32, 33, 37, 44] reported facilitators at the characteristics of the users level. Identified facilitators included training of implementers [32] and knowledge of implementers [44]. Additional facilitators reported involved those linked to intervention acceptability among youth, such as approachability or friendliness of implementers [33, 37] and experience of implementers [37].