There were 849 articles and 18 reports that were obtained through electronic search of databases. After screening for duplicates, 646 articles and 16 reports had their titles and abstracts reviewed by all the three authors. Of these reviewed articles and reports, 535 articles and 12 reports were excluded as their content was irrelevant to this study. This meant that 111 articles and 4 reports were reviewed to determine whether or not they met the inclusion criteria. After reviewing the articles and reports the three authors resolved that 32 articles and one report met the inclusion criteria and there were then analysed. These results are summarised in the PRISMA flow diagram on Fig 1. Furthermore a Systematic Review protocol is appended as a supplementary file so as to clearly specific what this review sought out to achieve.
3.1 Outcome of Quality Assessment Tools
All selected articles were subjected to the 14 point quality assessment tool and met the minimum standards required. The AMSTAR tool results on Methodological Quality pointed out that the methods used were of sufficient quality to address the research questions of this systematic review. These findings are presented on Table 4.
3.2 Definition of Sexual Health
The definition of sexual health has evolved over the years leveraging on the 1975 World Health Organization that defined sexual health as “Integration of the somatic, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love” [14, 21, 22].The change in these definitions have been influenced by political, social, historic events and human right considerations [3, 21]. After the sexual revolution in the 1960s, there has been an on-going struggle over reproductive rights, rights for homosexuals and abortion rights for adolescents . These struggles are influenced by different contextual factors with some countries rejecting implementing or aligned to adopt some of the proposed sexual rights [23, 24].These have influenced the way health systems are structured in different countries with different contextual features resulting in varying adolescent sexual health outcomes.
3.3 Attributes, Antecedents and Consequences of HSSs in relation to ASH
Sexual health attributes that were obtained from literature were: contextual, dynamic, activism and advocacy and inefficient. Literature sources reporting these attributes are summarised on Table 1.
There is no consensus in how sexual health is defined, interpreted and infused into HSs within different communities in different countries [21, 22]. HSSs that are implanted in different communities in different countries are influenced by different contextual factors such as political environment, culture, religion and many more that will be prevailing at that specific time and point [14, 21, 22]. There is also need that the HSSs align and observe different societal values and expectations .
Different HSSs are implemented to address ASH issues in response to the ever changing environments [26-29]. It is presented that strategies to address sexual health issues have evolved in line with the ever changing environmental and contextual factors leading to utilisation of different technological platforms so as to ensure relevance of the strategies in addressing ASH issues [14, 21, 22, 27, 29].
220.127.116.11 Activism and Advocacy
Most HSSs as identified in literature leverage on activism and advocacy to create demand for ASH programs [30-32]. Different strategies are demonstrated as health service providers utilise different strategies so as to involve adolescents and lure them into programs that target their knowledge, attitudes and behaviours so as to promote safe sexual practices [33-35].
Due to differences in adolescents age groups, social status , ethnic beliefs and expectations; designed HSSs are never comprehensive enough [14, 21]. It is therefore noted that most HSSs have their strengths and weaknesses, therefore putting some adolescent populations at risk whilst on the other hand giving advantages to other adolescent populations [25, 26, 36-38].
Antecedents that influence ASH that were reported in literature were: adolescent sexual rights, lack of understanding of what sexual health is, need for integrated ASH systems, available resources and type of society. Literature sources reporting these attributes are summarised on Table 2.
18.104.22.168 Adolescent Sexual Rights
One of the antecedent themes that arose from literature was the need to protect adolescents as a human right necessity / requirement [2, 39]. Authors argue that adolescent sexual rights such as the right to access sexual health information are more often violated [2, 39]. There are arguments that sexual education is restricted in schools or in religious setups thereby denying adolescents key information that would inform their decisions regarding sexual health . Most strategies have therefore been targeted at improving adolescent access to information and different strategies have been used by different health systems to disseminate as much information as possible on sexual health . Some of these strategies have leveraged on available technologies (social media, utilisation of sports just to name a few) to ensure that information is disseminated to adolescents . Authors further argue that the current health systems are rigid and violate adolescents rights . Flicker and Guta (2007) argue that there is need that adolescents be allowed to make their own decision in being part of researches that are meant to gather data that is aimed at improving their sexual health outcomes . They argue that involving parents in consenting to adolescents participating in sexual research silences them and this impacts negatively on the process of collecting data that answers questions regarding the expectations of the adolescents .
22.214.171.124 Lack of understanding of what sexual health is.
Sexual health definitions have evolved over the years and have been contextualised to suit certain specific environmental contexts [14, 21]. This has created varied definitions that are sometimes contradictory and create a lot of confusion with different countries contextualising the definitions to suit their contexts . The universal understanding of what sexual health entails is therefore influenced by cultural, social, political and environmental contexts and might differ from country to country or continent to continent [14, 21]. HSs therefore have been designed in a way that lacks comprehensiveness as there are varied expectations which normally undermine international expectations and recommendations regarding management of ASH issues [14, 21]. Some authors argue that most health service providers do not speak about sexual health issues as often as they are expected to so as to proactively address sexual health concerns of adolescent . Lack of such interaction has created huge gaps of knowledge in adolescents [37, 38]. It is also presented that most studies evaluating the impact of different HSSs on promoting sexual health in young people often lack methodological rigour leading to uncomprehensive conclusions and recommendations that do not fully inform policy makers on the direction that they should take with their strategies if they are to promote safe sexual practices in young people .
126.96.36.199 Need for integrated ASH systems
Adolescents need to be exposed to programmes that enhance their skills in negotiating for safe sexual behaviours . The approaches or strategies used should be comprehensive in providing them with skills that enhance their ability to make beneficial relationships (with their parents, guardians and adults in general) that are supportive and offer them guidance towards career prospects that are economically sound [5, 42]. ASH strategies should therefore go beyond sexual issues to provide an integrated platform to ensure wholesome development in these adolescents . Strategies targeting these groups should therefore be driven by the need to facilitate development and enhance skills well beyond sexual health issues and offer equal opportunities for both girls and boys . There is a gap that ASH programs are not integrated into main HS structures thereby leading to less time and resources being dedicated to this cause [11, 40].
188.8.131.52 Available Resources
HSSs are crafted on the basis of available resources to fund and sustain specific sexual health programs . Health service providers in resource poor settings avoid “opening a can of worms” that is, asking questions or following up on adolescent sexual health issues that would require more resources and time than the HS is able to offer at that specific time and point . Lack of resources leads to non-prioritisation of adolescent sexual health issues and avoidance of asking or following up on matters that might have a bearing on ASH issues [37, 38].
184.108.40.206 Type of society
HSSs are influenced by different ethnic values [25, 37]. Most people identify with different cultural norms that could be for or against certain HSSs . Strategies that clash with specific societal beliefs are bound not to work. Adolescents from poor settings such as those that are from rural areas are more at risk of suffering negative sexual health outcomes as compared to those in urban areas that have easy access to information and health facilities [26, 36]. Adolescents utilising Indigenous Health Systems (IHSs) often have poor health outcomes as compared to utilising Modernised Health Systems (MHSs) . Crafting and implementation of HSSs to address ASH issues are therefore leveraged on specific societal characteristics so as to generate demand for ASH services [14, 25].
Consequences of these attributes and antecedents were reported to be: Weak adolescent programs constrained by different factors, parallel or fragmented systems resulting in low impact, vulnerability and heightened risks for poor health outcomes and challenges in interacting with different ethnic groups and gender. Literature sources reporting these consequences are summarised on Table 3.
220.127.116.11 Weak adolescent programs constrained by different factors
Adolescent sexual health programs normally fail to achieve desired health outcomes. There is existence of stigma and controversial attitudes that undermine these adolescent sexual health programs rendering them ineffective . This exposes adolescents to incomprehensive programs that exacerbates their vulnerability particularly fuelling confusion in how adolescents are expected to conduct themselves regarding sexual health issues . Adolescents therefore become victims of sexual violence, early pregnancies, unsafe abortions and STIs [2, 5].
18.104.22.168 Parallel or fragmented systems resulting in low impact.
I was revealed that a number of ASH programs are delivered as specific fragments addressing specific programs . Sexual health programs such as those addressing STIs, HIV and AIDS and family planning are normally funded by different organisations leading to a fragmented approach in addressing ASH issues . Most HSSs therefore lack comprehensiveness and run parallel to each other though delivered to the same recipients leading to conflicts, duplication, confusion and inefficient utilisation of resources .
22.214.171.124 Vulnerability and heightened risks for poor health outcomes.
Adolescents are placed at heightened risks for poor sexual health outcomes due to non-compatibility of HSSs with their developmental needs in relation to their specific age groups [3, 27, 42]. There is need to contextualise strategies in such a way that it takes into consideration the different developmental stages and the needs of these adolescents thereby ensuring that the strategy used is appropriate to attain desired goals [5, 27-29].
126.96.36.199 Challenges in interacting with different ethnic groups and gender.
Authors point out that no matter how accommodating some HSs are to adolescents, some ethnic groups were born from less liberal communities and are not forth coming in discussing sexual health related issues . It is also presented that gender plays an important role as some health service providers prefer discussing sexual related issues with service recipients of the same sex [37, 38]. This disadvantages some service recipients as they are denied the chance to be given information that they could pass on to their children in cases of adults thereby disturbing sexual health information dissemination . There are also challenges where most health service providers find it challenging to discuss sexual health issues with homosexuals . These challenges create barriers in HS functions in terms of information dissemination that is expected to foster safe sexual practices in adolescents [23, 24, 37].