Adolescent and Young Adult-Friendly Primary Health Care Services in Low- and Middle-Income Countries: A Scoping Review

doi:10.21203/rs.3.rs-4882500/v1

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Systematic Review

Adolescent and Young Adult-Friendly Primary Health Care Services in Low- and Middle-Income Countries: A Scoping Review

https://doi.org/10.21203/rs.3.rs-4882500/v1

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Introduction: A comprehensive and innovative adolescent health care programme focusing on adolescent health problems in low- and middle-income countries (LMICs) is lacking. We reviewed the research literature on models for adolescent and young adult (AYA)-friendly primary healthcare services (LMICs).

Methods and Analysis: This scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review. The PubMed, Embase, and Scopus databases were searched. The data were screened with COVIDENCE software® and extracted thematically.

Results: Together, the search generated 1101 articles, 40 of which met the inclusion criteria. The significant domains identified for AYA-friendly healthcare care services in LMICs were health facilities, health literacy, and the environment and empowerment, which were derived from eight themes, namely, appropriate package of services, facility characteristics, data and quality improvement, providers’ competencies, adolescent health literacy, equity and nondiscrimination, community support, and adolescent participation.

Conclusion: The friendly primary health care services model in LMICs should pay attention to health facilities, literacy, and environmental support. The identified domains provide insight for advising and implementing primary healthcare services that provide a trusted, holistic, comprehensive, integrated, and ongoing health service to AYA, thereby closing the gap in healthcare services for AYA.

Adolescents and young adults

Health services

Health care

Model

Low- and middle-income countries

The adolescent years are a crucial time in human development when significant physical and psychological changes occur to transition into adult life. According to the World Health Organization (W.H.O), “adolescents” are people aged between 10 and 19 years, “youths” are those aged between 15 and 24 years, whereas “young people” are people aged 10–24 years^1,2. Approximately one-sixth of the world’s population are adolescents (1.2 billion people), with almost 90% of adolescents living in low- and middle-income countries³. These young people, therefore, play a critical role as partners in, and contributors to, the global Sustainable Development Goals of ending poverty, improving health and education, reducing inequality, and spurring economic growth⁴. To accomplish these goals, young people require opportunities to acquire character, independence, understanding, knowledge, attitudes, and skills in various fields⁵. Ensuring their health and well-being is, therefore, recognized as of utmost importance for their current growth and development, and to secure the well-being of the future adults they will become and of the children they will have⁶.

Many Southeast Asian nations, including Indonesia, have forecasted the demographic benefits of adolescents between 2020 and 2030^7,8. Noncommunicable diseases (NCDs), injuries, and smoking have become more prevalent among adolescents and young adults (AYA)^8, along with risky behavior and reproductive health concerns⁹.

The W.H.O has already established the Global Standards to Improve Quality of Health (GSIQ) care services for adolescents¹⁰, which covers all aspects of health care services, from how the service should be delivered to evaluation and community participation. To engage young people in preventive and episodic care, primary care is ideally placed in the communities in which they live and go to school¹¹. However, in practice, primary care specific to adolescents is limited to low- and middle-income countries (LMICs)¹².

Comprehensive and innovative adolescent health care services focused on supporting healthy adolescent development and preventive and early interventions for health risks urgently require wider implementation in LMICs. The present review aimed to scope models of adolescent services implemented in LMICs and to synthesize the essential elements for successful implementation and adolescent health outcomes for future service development.

The scoping review has the following framework¹³: (1) formulation of the research questions; (2) identification of relevant studies; (3) selection of studies; (4) data charting; and (5) collection, synthesis, and reporting of findings. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR) was also used to visualize the workflow¹⁴.

Stage 1: Formulation of the research questions

The focal question of this scoping review is “What are the models for AYA-friendly primary health care services in LMICs?”

Stage 2: Identification of relevant studies

Using three electronic databases, i.e., Pubmed, Embase, and Scopus, a comprehensive literature search was performed in July 2023 to identify articles that include services or facilities for the AYA-friendly primary health care services model, with a focus on LMICs. The search strategy was developed for each database via Boolean phrases and MeSH terms via the main keywords “adolescents” or “young Adults” AND “primary health care” or “primary care” or “Youth Services” AND “low- and middle-income countries” AND “satisfaction” or “community involvement”. Manual searches for additional articles from the references of the retrieved articles were performed to expand the search.

Stage 3: Study selection

The search team (MFS, MA, and VSK) used keywords to search for and input the search results into the Mendeley library. They subsequently input all the metadata for each article, including the abstract, and upload them to COVIDENCE®. The titles and abstracts identified from the evidence-gathering process were independently screened. For studies meeting the eligibility criteria or where there is insufficient information to make a clear decision, full reports were obtained, and three authors (MFS, MA, and VSK) then independently assessed the full-text articles to establish whether the studies met the eligibility criteria. Any discrepancies were resolved by discussion. If resolution was not possible, a third author (RAW) who was not involved in the selection process was consulted. All steps were carried out with COVIDENCE®.

Studies not meeting the eligibility requirements were discarded. We included only the articles that met the following conditions: 1) were primary healthcare-related and published literature; 2) involved adolescents and young adults; 3) were published within the last 10 years; 4) were written in English or Bahasa Indonesia; and (5) had LMICs as the study setting. We excluded study protocols and articles describing services not conducted by healthcare workers. Weekly discussion or collaboration among the reviewers was performed to settle any disputes.

Stage 4: Data charting

Three authors (MFS, MA, and VSK) independently extracted the data from each eligible study via the data extraction form in Microsoft Excel. The descriptive characteristics of the studies, including study design, settings, and focus program/intervention, were gathered. The details of the services or models in the studies were summarized, as were the outcome evaluation and recommendations.

Stage 5: Collection, synthesis, and reporting of the findings

The data extracted in Stage 4 were qualitatively analyzed via a deductive approach by the authors (RAW, VSK, MFS, and MA). The details of the services or models extracted were organized into subthemes to depict the main issues raised in the literature. The following eight subthemes were adapted from the Global Standards to increase the quality of healthcare services for adolescents: health literacy; community support; appropriate package of services; providers’ competencies; facility characteristics; equity and nondiscrimination; data and quality improvement; and adolescents’ participation¹⁵. Keywords associated with the subthemes were identified from the details of the services or models. From the eight subthemes, further categorization into the following three themes was carried out: health facilities described the subthemes related to the services and resources from health facilities, health literacy described subthemes related to efforts to increase literacy, and the environment and empowerment described subthemes related to the involvement of the community and adolescents themselves in the service model. The results of the coding analysis were discussed with all the authors until an agreement was reached.

Description of studies

This review identified 40 articles that met the selection criteria (Fig. 1).

The study characteristics are shown in Table 1.

Table 1

Outcome and characteristics of the studies
Author/year	Type of study	Setting/place	Focus program/intervention	Successful outcomes	Challenges
Arije et al. (2022)¹⁶	Cross-sectional study	Public primary and secondary health facilities — Nigeria	Sexual and Reproductive Health Service — Provision and experiences of care in Sexual and reproductive health (SRH) services for adolescents and young people (AYP) in a Nigerian setting.	MCs’ medical history (90.3%), social record (63.9%), sexual/reproductive history (53.5%), and contraceptive experience (66%) were not obtained in most of the visits. Women had a lower AHQOC index rating on average than men (β = −0.3, 95% CI: −1.6–1.0, p = 0.687), rural health facilities had a lower AHQOC index rating on average than urban health facilities (β = −2.7, 95% CI: −5.1 – −0.2, p = 0.031), and a higher ranking of the health worker on the scale of 1–10 corresponded to a higher AHQOC index of the MC visit (β = 1.9, 95% CI: 1.6–2.1, p < 0.001).	This study found gaps in the competencies of the health workers, nonuse of educational materials in clinic encounters with young people, as well as the differential perception of quality-of-care by male and female AYP.
Vilalobos et al. (2017)¹⁷	Cross-sectional study	Primary care units — regional and rural & urban levels in Mexico	Sexual and Reproductive Health Service — A sexual and reproductive quality-of-healthcare index.	At the national level, 13.9% (95% CI: 6.9–26.0) of healthcare units provide low quality, 68.6% (95% CI: 58.4–77.3) medium quality, and 17.5% (95% CI: 11.9–25.0) high quality reproductive healthcare services to adolescents.	Limitations of this study include the fact that the quality-of-care in reproductive healthcare is multidimensional and has no standardized metric, leading to scales measuring different aspects and limiting comparison across populations.
Bomfim et al. (2020)¹⁸	A descriptive cross-sectional quantitative study	Marrere Health Centre — Mozambique	Sexual and Reproductive Health Service — evaluation of good care and service principles, communication with the patient, privacy and confidentiality, information about family planning (FP), and general satisfaction.	The “overall satisfaction” rate was more frequent in both groups, being answered by 93.8% of youth and adults (≥ 19 years) and 72% of adolescents, showing a statistically significant difference between the two groups (p < 0.05).	Health provider (HP) practice is poor with partial adherence to service protocols, but there are significant deficiencies in the type of information and manner of communication with adolescent users, especially regarding FP.
Chikalipo et al. (2018)¹⁹	A cross-sectional exploratory study	Ndirande Health Centre in Blantyre — Malawi	Sexual and Reproductive Health Service — pregnant adolescent girls’ perceptions of the antenatal care received.	Two major themes emerged from the findings: a) caring and b) motivation for attending antenatal care.	The researchers, being insiders who practiced with students at the clinic and had experienced the care provided to the pregnant adolescents, had to be neutral to avoid bias, which at times was difficult to achieve. However, probing was conducted during interviews to gain deeper understandings of their perceptions.
Lovero et al. (2022)²⁰	Qualitative - interview and focus group	Mozambican primary care — Mozambique	Mental health services — identified determinants to the implementation of mental health services for adolescents in low- and middle-income countries (LMIC).	Through a series of stakeholder workshops focused on implementation strategy selection, prioritization, and specification, we then developed an implementation plan comprising 33 unique strategies that target determinants at the intervention, patient, provider, policy, and community levels.	Qualitative implementation, determinant data collection, and implementation strategy selection workshops occurred in one province.
Bhana et al. (2015)²¹	Pilot trial (experimental)	HIV/AIDS Clinic — South Africa	HIV patients obtain a family-based psychosocial intervention. The program provides step-by-step instructions for counselors to deliver crucial information to encourage talks and problem-solving within and among families in multifamily groups.	Antiretroviral therapy (ART) adherence reports have improved (VUKA = 1.10; control = − 0.43 at baseline and follow-up, p < 0.05). Caregiver's' comfort level while discussing delicate subjects with their kids changed (VUKA = 0.26; control = − 0.54, p < 0.002), and they also showed a tendency to feel less stigmatized (− 0.21) than carers in the control group (0.28, p < 0.09) Participants in the intervention group showed greater improvements in treatment knowledge (VUKA = 0.27; control = -0.74, p < 0.08) and caregiver-child communication (0.41 vs -0.07, p < 0.09) compared to the control group.	The study's limitations are the use of self-reported adherence measures and the limited sample size. Additionally, there's a chance that some of the study participants were bias.
Kaihin et al. (2016)²²	Pilot trial (experimental)	HIV/AIDS Clinic — Thailand	A training session focused on empowerment for adhering to ART. Eight training sessions about accepting responsibility, recognizing reality, and reflecting critically led by skilled nurse researchers.	After the intervention, the experimental group had 95% ART adherence, significantly greater than the control group (χ2 = 14.723; df = 1; p < 0.001) and higher than the preintervention (McNemar χ2 = 18.070; df = 1; p < 0.001).	There wasn't much time for follow-up. Examining the sustainability of this form of action is therefore necessary. It should be noted that this was a labor-intensive strategy and implementing it across several places might have been quite costly. But in Thailand, there's a huge financial disparity between keeping a patient on a first-line ART regimen and needing to utilize a second-line combo.
Van Rossem and Meekers (2000)²³	Quasiexperimental	Community – Urban Cameroon	Social marketing and mass media campaign for reproductive health. Youth-oriented promotional events, radio talk shows, brochures, and other media. Youth clubs Peer educators and counseling (discuss a wide range of sexual health topics, including unwanted pregnancy, delayed onset of sexual activity, and the means to prevent transmission of HIV and other sexually transmitted diseases).	More male youths than female youths reported to have started to use contraceptives, (1) = 4.50, p = 0.034), to have visited a health center (x2 (1) = 7.21, p = 0.007), and to have discussed sex with parents (x2 (1) = 24.97, p = < 0.001) and teachers (x2 (1) = 16.84, p = < 0.001). Female youths, in turn, more often reported “other” behavior changes than male youths (x2 (1) = 10.48, p = 0.001).
Girase et al. (2022)²⁴	Policy review	Community — five ministries of the Government of India	Review of policies, programs, and legislations of youth mental health across five ministries of the Government of India—Health and Family Welfare, Education, Women and Child Development, Youth Affairs and Sports, and Social Justice and Empowerment.	Key programmatic initiatives across five key ministries that can support young people’s mental health in India. Health facility: 1. Basic psychiatric care 2. Adolescent-friendly health clinic 3. Telemedicine (improving access to specialists) School and college: 1. Peer education 2. Life-skill education 3. Drug/substance abuse 4. Screening for health problems (school health program) Community Outreach: 1. Health and wellness awareness through community 2. Provision of apps (SAATHIYA SALAH)	In India, states may develop specific initiatives to address their specific priorities over and above these national level initiatives. Such state-specific initiatives were not identified. The policies and programs and their implementation plans lacked a comprehensive discussion on adoption of transdisciplinary approaches, thereby limiting the inferences for enabling an intersectoral coordinated approach and specific implementation strategies.
Nair et al. (2015)¹⁵	Review article	Bangladesh, Bhutan, Burkina Faso, Congo, Ethiopia, Ghana, India, Indonesia, Kyrgyzstan, Lesotho, Malawi, Mongolia, Myanmar, Nicaragua, Philippines, Moldova, South Africa, Sri Lanka, Tajikistan, Tanzania, Thailand, United Kingdom (England, Scotland), Ukraine, Vietnam, and Zambia	Global standards of the Quality of Health Care Services for Adolescents.	Development of eight Global Standards and 79 criteria for measuring them: 1. Adolescents’ health literacy 2. Community support 3. Appropriate package of services 4. Providers’ competencies 5. Facility characteristics 6. Equity and nondiscrimination 7. Data and quality improvement 8. Adolescents’ participation	Apart from the actions in the facility and community, national- and district-level actions will be necessary in each of the health system pillars to enable health care providers and managers to implement the standards and their criteria.
Michelson et al. (2019)²⁵	Prospective cohort design	Three secondary schools — India	Transdiagnostic psychological interventions for common adolescent mental health problems: Pilot 1: problem- and emotion-focused coping using a guided self-help modality. Pilot 2: problem-focused coping addressed through counsellor-led face-to-face intervention.	The SDQ Impact score (d = 0.65; 95% CI = 0.01–1.26) and the SDQ Total Difficulties score (d = 0.40; 95% CI = − 0.20–0.98) both showed attenuated effect sizes with broad confidence ranges. The YTP (d = 0.01; 95% CI = − 0.36–0.36) was one of the outcomes measures with even smaller effect values.	We do, however, recognise that because of the small sample sizes, lack of a priori control conditions, and lack of long-term follow-up, the varied outcomes presented in our pilot trials must be taken as preliminary and interpreted cautiously. Based on the data that remitted (adult) participants in low-intensity psychological therapies may exhibit significant relapse rates within a year, the latter is particularly crucial.⁶⁷ Additionally, the demand features of the assessments in Pilot 1, which had psychologists perform baseline measurements, might have had an impact on the results and could account for the first pilot's trend towards comparatively greater effect sizes on several outcome measures.
Wagner et al. (2017)²⁶	Pilot trial	Two clinics within National Hospital — Kenya	A continuous quality improvement (CQI) intervention is being carried out at youth HIV testing sites to enhance the quality of AYA HIV testing services (HTS).	HIV prevention knowledge: • An increase at VCT from 46% at baseline to 61% at the end of the intervention [aRR 2.17, 95% CI: 0.93–5.04, P = 0.071; aRD 39 percentage points, 95% CI: 2–76, P = 0.038]. HIV transmission knowledge: • •Accurate knowledge of HIV transmission increased from 18–63% in the youth centre (aRD 42% points, 95% CI: 21–63, P 0.001; aRR 2.27, 95% CI: 1.05–4.94, P = 0.038); meaningful • At VCT, accurate transmission knowledge showed an increasing trend from 38–72% (aRD 30 percentage points, 95% CI: 4–63, P¼0.080; aRR 1.72, 95% CI: 0.76–3.90, P = 0.194) Satisfaction: • In both the youth center and VCT, satisfaction with testing was high during both baseline and intervention periods, and there was no change over time (youth center: 4.5 vs. 4.5, P¼ 0.384; VCT: 4.5 vs. 4.5, P = 0.755).	CQI may be as successful as training treatments for focused change like knowledge enhancement, but it has limits in terms of cost and complexity. More research is required to ascertain the most effective environments for this intervention, the kinds of pre-CQI activities that prepare a site for change, and the long-term viability of CQI in settings with limited resources if additional resources are not available to support the CQI process.
Geary et al. (2014)²⁷	Qualitative - semistructured interviews	Seven publicly funded primary healthcare clinics and a larger health center — South Africa	Youth-friendly services (YFS) program — to address the following topics at each health facility: the services available to young people, opening hours, confidentiality, perceived community support for the provision of health services to young people, provision of the YFS program or other activities related to youth-friendly health services, and reflections on providing health services to young people.	Barriers to provision reported by nurses were: lack of youth-friendly training among staff and lack of a dedicated space for young people. Four of the eight facilities did not appear to uphold the right of young people aged ≥ 12 years to access healthcare independently. Breaches in young people’s confidentiality to parents were reported.	1. The relatively small sample of respondents and the focus on one geographical area. 2. Conducting interviews in English rather than the local language of Shangaan
Chandra-Mouli et al. (2016)²⁸	Review article	Bangladesh, India, Indonesia, Malawi, Maldova, Mongolia, Tanzania, and Ukraine	Adolescent-friendly health services — Analyzed national quality standards for adolescent-friendly health services, findings from the assessments of the quality of health service provision, and findings on the utilization of health services.	Gathered normative guidance and reports from eight LMICs in Asia, Africa, Central and Eastern Europe and the Western Pacific. The governments of LMICs have set out to improve the accessibility, acceptability, equity, appropriateness, and effectiveness of health service provision to adolescents by defining standards and actions to achieve them. Their actions have led to measurable improvements in quality and to increases in health service utilization by adolescents.	The attributes assessed and methods used were broadly similar across assessments. Another strength is greatly varied level of rigor. Given this, a meta/analysis was not possible.
Subramanian et al. (2022)²⁹	Review of models and actions for implementation	School-based programs and health clinics — Six countries in Subsaharan Africa and South America	HIV care for adolescent programs — used a three-step process to develop a tailored conceptual framework focused specifically on the integrated delivery of care to adolescents within HIV care programs.	Developed an implementation science-informed conceptual framework for integrated delivery of HIV care to adolescents and applied the framework to summarize key data elements in 10 studies or programs across seven countries. The key pillars of the framework included 1. The socioecological perspective 2. Community and health care system linkages 3. Components of adolescent-focused care. The conceptual framework and action steps outlined can catalyze design, implementation, and optimization of HIV care for adolescents	Despite resource constraints and capacity challenges, countries with populations disproportionately impacted by HIV are attempting to implement programs to improve delivery of adolescent health care services.
Toulabi et al. (2012)³⁰	Randomized controlled trial	High schools —Khorram Abad — Iran	The “behavior modification” interventional program — nutritional education, modifying dietary habits, teaching exercise programs, teaching nutritional facts to the parents, and performing exercises 3 days a week.	Adolescent’s mean weight, body mass index (BMI), and waist and hip circumferences decreased significantly after implementing the interventional program in the intervention group (p 0.001). Additionally, the students’ and parents’ nutrition knowledge increased.	None
Leme et al. (2016)³¹	Randomized controlled trial	School in São Paulo city — Brazil	Healthy Habits, Healthy Girls—Brazil program — the measures were BMI, BMI z score, waist circumference, and various sedentary and dietary health-related behaviors.	Differences favored the intervention group (adjusted mean difference, − 0.26 kg/m², SE = 0.018, p = 0.076). Statistically significant intervention effects were found for waist circumference (− 2.28 cm; p = 0.01), computer screen time on the weekends (0.63 h/day, p = 0.02), total sedentary activities on the weekends (− 0.92 h/day, p < 0.01), and vegetable intake (1.16 servings/day, p = 0.01).	There are some limitations that should be noted, including the self-report measures of PA, screen time, and dietary intake.
Leme et al. (2018)³²	Clinical trials randomized controlled trial	Low-income communities in the city of São Paulo — Brazil	“H3G-Brazil” “Healthy Habits, Healthy Girls — Brazil” — obesity prevention program on weight status and weight-related behaviors.	Meaningful increases occurred in the waist circumference for both groups; the intervention group presented a lower increase (F = 3.31, p = 0.04).	The use of self-report measures to evaluate changes in health-related behaviors; a low follow-up retention rate; the lack of an adjustment for the large number of tests performed; Weight status based on waist circumference and BMI measurements, which are imprecise indicators of total body fat; very targeted nature of the intervention, which might not apply to other groups (e.g., participants who are male, come from other socioeconomic backgrounds, live in different parts of Brazil, or reside in other LMICs); The study findings may have been impacted by statistical disparities between the groups at baseline, even though the groups were randomized following baseline assessments. Additionally, the sample size was insufficient to investigate effects.
Dunker and Claudino (2018)³³	Randomized controlled trial	Public schools located in São Paulo City - Brazil	Brazilian NMP — Sports, dietary assistance, motivational interviews, group lunches, and parent education materials were all included in the NMP. The Body Shape Questionnaire was our principal product (BSQ).	There were no notable changes in our measured outcomes because of the New Moves program.
Aninanya et al. (2015)³⁴	A community-randomized trial	Communities. Ghana. Rural district of Northern Ghana	Services for sexual and reproductive health: 1. Engagement to establish a nurturing atmosphere; 2. Education of healthcare professionals in YFHS methods 3. A curriculum for sexual health education provided in schools 4. Peer engagement outside of the school	After controlling for baseline differences, exposure was linked to more than twice the odds of using STI services (AOR 2.47; 95% CI: 1.78–3.42), 89% greater odds of using perinatal services (AOR 1.89; 95% CI: 1.37–2.60), and 56% greater odds of using antenatal services (AOR 1.56; 95% CI: 1.10–2.20) among participants in the intervention versus comparison communities.	Since there were four components to the intervention, it was not possible to identify in this study which component or components had the greatest impact on the outcomes. Recall bias, unmeasured confounding, and loss to follow-up are further possible drawbacks. As there were no notable distinctions between the comparison and intervention communities, the main causes of loss to follow-up were migration and absence during interview visits; as a result, it was unlikely to have had a substantial impact on the study's findings. Given that participants were asked to recollect service usage over a 12-month period, recall bias may have understated certain service usage. Any big study may contain some unmeasured confounding, but this was anticipated to be comparable in both groups.
Dagnew et al. (2015)³⁵	Cross-sectional study	Community Households in Dejen District — in East Gojjam Zone, Amhara Regional State Rural — Ethiopia	Health service utilization: the use of contemporary medical services, whether preventive or curative, by adolescents with psychological, physical, and social health issues in various public and private health facilities.	Of the 690 teenagers, 313 (45%) made use of medical services. Sixty-nine of these (60.7%) were pleased. A number of factors were found to be predictive of satisfaction: physical proximity (AOR = 3.6, 95% CI: 1.8–7.3); drug availability (AOR = 2.7, 95% CI: 1.3–5.8); availability of health services (AOR = 2.5, 95% CI: 1.1–6.0); treatment in a separate room (AOR = 2.9, 95% CI: 1.4–5.6); evaluating all adolescents problems (AOR = 4.0, 95% CI: 2.0–8.5); treated with respect (AOR = 3.0, 95% CI: 1.4–5.7); and opportunity to explain feelings (AOR = 3.3, 95% CI: 1.7–6.6) were predictive factors.	A greater number and strength of youth-friendly health service facilities should be established by various organizations at various levels, services should be provided in an appropriate manner, and health professionals' ability to interact with young people should be improved.
El-Abassy et al. (2020)³⁶	Quasiexperimental research one group pretest and posttest	School — Saris Alliyan Aljadida Preparatory school, Menoufia governorate, Egypt	Positive Psychology Intervention — a constructed interview questionnaire, Brief Symptom Inventory, General Self-Efficacy Scale, Life Orientation Test-Revised, Rosenberg Self-Esteem Scale, Satisfaction with Life Scale, and The Oxford Happiness Questionnaires.	The current study’s findings proved there were significantly greater increases in self-efficacy, self- esteem, optimism, and life satisfaction scores from preintervention to postintervention. Moreover, there were significantly greater increases in the happiness level from preintervention to postintervention.	None
Galagali et al. (2021)³⁷	Review article	India	Telemedicine — The latest research endorses telemedicine as a successful strategy in resource-limited settings to provide accessible and equitable healthcare.	Telemedicine is likely to become an integral part of healthcare services in the post pandemic era. In a resource-limited country with a vast child and adolescent population and difficult terrain, telemedicine has facilitated ‘health for all’. This model of pediatric and adolescent telehealth in India can be replicated by other LMICs.	None
Gill et al. (2022)³⁸	Focus group qualitative study	Five health facilities in two counties (Homa Bay and Turkana) — Kenya	Enhanced adherence counseling Targeted client counseling strategy led by adherence counsellor or peer educator that aims to identify and address barriers to ART adherence to facilitate viral suppression.	The fear of being stigmatized or discriminated against because of their HIV status, as well as their interactions and level of support received from caregivers, underpinned, and often undermined adolescents’ drug-taking behavior and progress toward more independent medication management.	However, problems were noted with facility based, individual EAC counseling, including judgmental attitudes of providers and difficulties traveling to and keeping EAC clinic appointments.
Heizomi et al. (2020)³⁹	RCT	Female high school — Iran	School-based mental health promotion program Stress management skills training program of six sessions provided by a psychologist and environmental changes in school include decoration and counseling.	For psychological well-being, significant differences were found in the proportion of participants reporting low (34.48% before intervention vs. 26.89% after intervention) and high (65.51% before intervention vs. 73.1% after intervention). After the intervention, statistically significant improvements were found only in life satisfaction, happiness, and stress in both the intervention and control groups, but the differences were more significant in the intervention group (p ≤ 0.001), as compared to the control (p ≤ 0.05) group.	Our findings also highlighted the importance of ongoing support provision during program implementation. As continual and long-term implementation of such interventions in schools seems to be with difficulties, school health policymakers should focus on school teachers in general and school healthcare providers/nurses in particular, as those who can provide students with ongoing mental health support in the schools.
Phiri et al. (2022) ⁴⁰	Cluster randomized trial	Community-based-hub in two urban communities — Zambia	Community-based hub for SRH services. The delivery of comprehensive SRH services, including HIV service through community-based spaces (hubs) with a prevention points “loyalty” card system to incentivize service use.	Overall, 73.3% (n = 735/1,002) of AYP in the intervention arm knew their HIV status, as compared to only 48.4% (n = 479/987) in the control arm (adjusted prevalence ratio (adjPR) = 1.53 95% CI: 1.36–1.72; p < 0.001.	The trial was not without its restrictions. Approximately 35% of the AYP who were randomly chosen to participate in the end-line survey were unable to be contacted because they had moved—either outside of the community or out of the zone in which they were living in 2019—or they had not been contacted at the time of the survey. The results may be skewed if these people knew their HIV status more or less than survey respondents did, for instance, if those on the go were less likely than stable residents to have visited Yathu Yathu centres.
Kumar et al. (2023)⁴¹	Cross-sectional	Two primary health care facilities — Nairobi	Experiment using discrete choice to determine treatment preferences for depression among adolescents quantitatively. Pregnant teen girls' preferences for depression treatment are evaluated in an unofficial urban setting.	When it came to the provision of services, the respondents preferred separate adolescent-friendly services to being offered services at the ANC with adult mothers (63.7%, β = -37.92, p < 0.001). Compared to peer-support-based skills, parenting skills training was preferred by respondents more (56.7%, β = 19.6, p < 0.001). Returning to school was preferred less than livelihood training (77.3%, β = −19.3, p < 0.001) when it came to future training needs. The respondents preferred facility nurses (52.8%, β = 6.04, p < 0.001) over CHVs for conducting intervention delivery sessions.	The research was carried out at two healthcare facilities inside the Nairobi Metropolitan Services Health Facility, situated in an informal urban setting. It is possible that the findings cannot be fully extrapolated to other practice models and settings. Consequently, the use of findings is still restricted to urban informal communities.
Laurenzi et al. (2021)⁴²	Systematic review and meta-analysis	United States, sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand)	Psychosocial intervention for Adolescent and Young People Living with HIV (AYPLHIV) Psychological, social, and/or behavioral approaches, which may include activities, techniques, or strategies delivered through interpersonal or information means.	ART adherence, ART knowledge, viral load information, risky sexual behaviors, risky sexual knowledge, retention in care, and linkage to care were among the outcomes of interest. Overall, the psychosocial therapies for AYPLHIV had significant, small-to-moderate impacts on viral load (SMD = 0.2607, 95% CI: 04518–0.0696, 12 trials, n = 1566) and adherence to antiretroviral therapy (ART) (SMD = 0.3907, 95% CI: 0.1059–0.6754, 21 studies, n = 2647). The psychological therapies that were examined did not show any noticeable impact on AYPLHIV retention in care (n = 8), hazardous sexual behaviors and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5), or linkage to care (n = 1).	Research focusing on behavioral outcomes, including SRH, is essential as the studies we found had less of them than those that were HIV-specific. Furthermore, the included studies' conclusions should be interpreted in light of the fact that they do not fairly depict the geographic distribution of HIV infection among AYP worldwide.
Meherali et al. (2021)⁴³	Scoping review	Ethiopia, Cote d’Ivoire, Lebanon, Kenya, Jordan, South Africa, Ecuador, Brazil, Global	Adolescent’s sexual and reproductive health delivery in pandemic setting.	Several treatments were developed and recommended to address SRH and adolescents' access to SRH services in low- and middle-income countries (LMICs) during and after the COVID-19 pandemic, according to findings from the studies and policy papers included in this review. Healthcare professionals are involved in ensuring that patients have access to age-appropriate, accurate, and current information on SRH through media and pamphlets; providing contraceptives for longer periods of time; and using schools, mass media campaigns, and radio programs for comprehensive sex education, prevention of unwanted pregnancies, and raising awareness regarding hormonal therapies; Enhancing access to contraceptives through community-based delivery and pharmacies; Using telemedicine to provide adolescents with easy access to services like medical abortions, counselling, and screening; Adolescent-Friendly Phone Lines for Advice; Distribution of Condoms, Menstrual Supplies, HIV Preexposure Prophylaxis Medication (PrEP), Lubricants, and Douches; and Utilizing Digital Platforms to Improve Adolescent Socialization and Provide Psychosocial Services.	It may not be possible to extrapolate the scoping review's conclusions to non-LMIC nations. Furthermore, because to the cultural and socioeconomic differences across these nations, the results cannot be applied to all LMICs. Moreover, this scoping review only included publications published in English; studies on this subject published in any other language were not included.
Mehra et al. (2013)⁴⁴	Cross-sectional	Primary health center in Uttar Pradesh and Bihar State — India	Youth-friendly services. Analyzing key determinants of youth-friendly health services that influence client’s satisfaction.	Significant characteristic that influences client satisfaction (P < 0.001) are: availability of waiting area, Information that kept confidential, got the information they wanted, and supportive parents.	This study is restricted to the perspectives of the clients on the health services and reflect only part of the quality of the entire health care process.
Moise et al. (2017)⁴⁵	Cross-sectional	Public, private, religious and community association owned-centers and hospitals — Burundi	Reproductive health service (RHS) — applied both geospatial and nonspatial analyses, to examine the density of RHS availability and density, and to explore the association between youth-friendly practices and adolescent use of RHS in post conflict Burundi.	Found a stronger association between adolescents’ use of RHS and YFS practices. They found significant associations with facility characteristics, which have designated check-in and examination rooms (P < 0.00001) and programming characteristics, such as community outreach, privacy, and confidentiality (P < 0.01).	Its cross-sectional nature, with data collected at a single point. Given that the census data for Burundi do not provide age-specific population data, due to political reasons, it is not possible to discern the population for young people; neither for those aged 10–24 years from the general population.
Mugo et al. (2019)⁴⁶	Controlled trial	National Hospital — Kenya	HIV Care to AYA — standardized patient (SP) clinical training intervention to improve healthcare workers (HCW’s) “adolescent-friendly” competencies in providing HIV care to AYA (training included actors learning a ‘practice case’ plus a primary case according to case scripts, giving verbal feedback, and scoring HCW communication skills and identification of case goals).	SPs rated HCW interactions (mean Likert score out of 5, 95% CI): lowest in cases on fertility desire (3.6, 3.3–3.9), STI/GBV/alcohol abuse (3.6, 3.3–3.9), and disclosure/adherence (3.9, 3.6–4.2); and highest in cases on cognitive delay (4.6, 4.4–4.8), TB/PWP/FP (4.6, 4.4–4.8), and depression/sexual identity (4.4, 4.1–4.7). Actors rated HCW competency the highest in clear communication (4.7, 4.4–5.0), respectfulness (4.5, 4.1–4.9) and friendliness (4.5, 4.1–4.9), moderately in demonstrating interest in what the SP was saying (4.2, 3.7–4.7) and showing empathy (3.8, 3.2–4.5), and lowest in enabling SP to share sensitive information (3.7, 3.2–4.2) and allowing time for questions (3.5, 2.8–4.2).	A small sample with limited generalizability and assessment of competency based on self-report, which is prone to social-desirability bias.
Mulugeta et al. (2019)⁴⁷	A facility-based quantitative cross-sectional study supplemented by qualitative design	Two selected public health facilities — Southern Etiopia	Youth-friendly service — Assess youth-friendly service quality and associated factors at public health facilities (use WHO quality standard by combining the three quality assessment items for structure, process, and output/satisfaction level). Structural quality is concerned with the availability of adequate service providers, facilities, information, essential drugs, equipment, and basic infrastructures.	The variables that independently predict youth client satisfaction were age (15–19 years) [AOR (95% CI) = 3.2 (1.4–7.8)], employment [AOR (95% CI) = 6.4 (2–17)], place of YFS [AOR (95% CI) = 0.35 (0.1–0.8)], frequency of visit [AOR (95% CI) = 0.03 (0.0–0.3)], waiting time [AOR (95% CI) = 0.02 (0.0–−0.09)], and comfort with providers’ sex [AOR (95% CI) = 0.07 (0.02–0.2)].	1. The study is geographically limited, and it focused only on clients who visited public health facilities 2. In measuring each of the quality components, overestimations of the findings may happen 3. The study also shares the limitation of cross-sectional design as in this case as it is difficult to establish the temporal sequence.
Cumber et al. (2022)⁴⁸	Qualitative design through individual interviews	The Naguru Teenage Information and Health Centre (NTIHC) — Uganda	Maternal health services among pregnant adolescents - Describe the barriers and strategies needed to improve maternal health services in the clinics that provide youth-friendly services in Uganda.	Adolescents in Uganda face considerable barriers to accessing improved and quality maternal health services: lacking financial support, difficulties in reaching health facilities, experiencing discrimination, disrespect, and lack of privacy. To mitigate these barriers, according to the adolescents, considerable efforts are required to tackle health workers’ working conditions and sensitize the community on the importance of, as well as securing the availability of maternal health services for pregnant adolescents. Strategies needed for adequate maternal health care services include the following: working conditions for health workers need to improve, awareness in community and health workers needs to be accelerated, and men should be involved in maternal health care service.	1. The results were interpreted based on the context. Qualitative findings being contextual does not mean they have no meaning in other contexts; however, the context changes when findings are transferred. 2. The participants only included those who attended the youth-friendly clinic, i.e., NTIHC that could have led to selection bias.
Olashore et al. (2023)⁴⁹	Randomized controlled trial	Medical clinics — Botswana	Psychological interventions (PI) in HIV-infected adolescents — explore the effectiveness of PI: psychoeducation, problem-solving, and rehearsal strategies on depression and adherence in HIV-infected adolescents in Botswana.	The intervention group scored significantly lower on depressive symptoms (PHQ-9 [F (1,50) = 12.0, p = 0.001, ƞp2 = 0.20]) and higher on adherence score (Visual Analog Scale (VAS) [F (1,50) = 13.5, p = 0.001, ƞp2 = 0.22]) than the control group after 5 weeks. The post hoc analysis showed that the significant improvements in depressive symptoms (z = − 4.03, p < 0.01, r [effect size] = 0.88) and adherence (z = − 4.05, p < 0.01, r = 0.88) at posttest in the intervention group were maintained at 24 weeks.	1. Several limitations may have affected the present study, the first being the small sample size. 2. The effectiveness of the intervention is limited to mild-to-moderate depression. 3. The reliability of the VAS in assessing adherence may be low and subjective as compared to the other methods. 4. The self-report nature of the study may also have introduced a recall bias and inaccurate reporting of symptoms.
Pavarini et al. (2023)⁵⁰	Cross-sectional, descriptive survey	Registered users of the U-Report (UNICEF social messaging tool and data collection platform) — Burundi, Jamaica, Nigeria, South Africa, and Brazil	Mental health and well-being (MHWB) - Identify pathways for young people’s participation in promoting MHWB in LMIC (this study surveyed young people’s aspirations for engagement, their spheres of influence, capacity building needs, and key barriers to participation).	Young people’s core aspirations were to join a mental health awareness project and to support their peers. Participants considered schools and community settings to be the most important spheres for engagement. Lack of information about mental health was the main perceived barrier to participation, and mental health classes were the main training need. By recognizing young people as agents of change in the promotion of MHWB and providing opportunities for meaningful participation, we can develop innovative yet feasible solutions to one of the most pressing developmental goals of our time.	Survey participation was restricted to those registered on the U-Report platform, who were possibly already motivated by civic engagement values. These study items did not include youth involvement in addressing social, structural, and economic problems that are important determinants of mental health in LMICs (e.g., poverty, political instability).
Phiri et al. (2022)⁴⁰	Cluster randomized trial (CRT)	Two densely populated urban communities (which were split into 10 zones each) — Zambia	SRH - Adaptations to the Yathu Yathu intervention (provides SRH services through community-based peer-led spaces, consists of two key intervention components: (1) Spaces (hubs) located within the community away from the government-run health facility in each of the 10 intervention zones; (2) A prevention points card) in response to the COVID- 19 epidemic, and implications on uptake of HIV testing services (HTS) among AYP.	During hub closures, comprehensive sexuality education (CSE) was delivered via video on social media, resulting in an increase in Facebook page followers. WhatsApp groups evolved as a platform to deliver CSE and COVID-19 information, with higher participation among young people aged 20–24 years. Key service delivery adaptations included the following: reducing the number of participants in hubs, mandatory handwashing before entry, use of personal protective equipment by staff, and provision of facemasks to AYP. Uptake of HTS among AYP visiting hubs for the first time after COVID-19-related closures was higher (73.2%) than uptake before adaptations (65.9%; adjOR = 1.24 95% CI: 0.99–1.56, p = 0.06).	1. It was not possible to determine if the individuals reached through the Facebook page were study participants who received a PPC, as there were no restrictions on who could engage with the page. 2. It did not compare the uptake of HTS in the hubs with the uptake of HTS in the control zones (health facilities).
Taiwo et al. (2021)⁵¹	Single-arm trial	Infectious Diseases Institute — Nigeria	Two-way Text Message Reminder Intervention for Youth with HIV (YWH) — In a single-arm trial, participants received 48 weeks of a combination intervention, comprising daily of two-way text message medication reminders plus peer navigation (the peer navigators received didactic lectures and practicums, covering general professionalism, privacy and confidentiality, basic HIV education, human rights and protections, mental health, self-care, and roles and responsibilities of peer navigators).	The proportion of YWH with viral suppression was 35% at baseline, and 68% at 24 weeks, which is an increase of 94%. At 48 weeks, 60% were suppressed, an increase of 71% from baseline. Compared to baseline, the odds of being virologically suppressed were substantially higher at 24 (OR = 14.00, p < 0.001) and 48 (OR = 6.00, p = 0.013) weeks of the combination intervention.	1. We enrolled only 40 YWH in this single-arm study. 2. Although there were improvements in self-reported adherence by VAS, the correlations with viral suppression were weak and not statistically significant.
Van Lith et al. (2018)⁵²	A post procedure quantitative survey	14 facilities offering Adolescent Voluntary Medical Male Circumcision (VMMC) services to adolescents — South Africa, Tanzania, and Zimbabwe	Adolescent Voluntary Medical Male Circumcision (VMMC) services - Examined the overall satisfaction, comfort, perceived quality of in-service communication and counseling, and perceived quality of facility-level factors during VMMC services.	Altogether, 97.7% and 98.7% of the participants reported that they were either satisfied and very satisfied, respectively, with their VMMC counseling experience. Most were also very likely or somewhat likely (93.6% of 10–14-year-olds and 94.7% of 15–19-year-olds) to recommend VMMC to their peers. On a 9-point scale, the median perceived quality of in-service (counsellor) communication was 9 (interquartile range [IQR], 8–9) among 15–19-year-olds and 8 (IQR, 7–9) among 10–14-year-olds. The 10–14-year-olds were more likely than 15–19-year-olds to perceive a lower quality of in-service (counsellor) communication (score < 7; 21.5% vs. 8.2%; aPR, 1.61 [95% CI: 1.33–1.95]).	Given the cross-sectional study design, reported associations should be descriptively interpreted, and the measures for perceived quality must be taken in context of this particular study. The study population may contain selection biases, as the study only captured adolescents who had undergone VMMC and completed the post procedure survey.
Willis et al. (2019)⁵³	Randomized trial	Two clinics in the intervention arm and one larger clinic in the control arm — Zimbabwe	Community Adolescent Treatment Supporters (CATS) services — Effectiveness of CATS services on improving linkage to services and retention in care, adherence, and psychosocial well-being among adolescents living with HIV in Zimbabwe. Participants received the same standard of care and were also allocated to trained and mentored CATS for additional support and included a weekly home visit during which the CATS provided HIV and ART information and counseling as well as monitored the participants’ adherence and general well-being.	The intervention group was 3.9 times more likely to adhere to the treatment than the control group. Linkage to services and retention in care within the intervention group increased as compared to the control arm, which showed a decrease. The intervention group reported a statistically significant increase in confidence, self-esteem, self-worth (p < 0.001), and quality of life compared (p = 0.028) the control arm, which showed a decrease.	1. The sample size was small, and it may therefore not be possible to generalize about the larger population of ALHIV. 2. There was a relatively low response rate at the end line in the control arm as participants in this arm were not routinely attending clinic as scheduled.

ALHIV: adolescents living with HIV; aPR: adjusted prevalence risk; ART: antiretroviral therapy; CATS: Community Adolescent Treatment Supporters; CI: CI: confidence interval; HIV: Human Immunodeficiency Virus; IQR: interquartile range; VMMC: Voluntary Medical Male Circumcision

We included all 40 articles for further extraction to identify the domains for the models of AYA-friendly primary healthcare services in LMICs.

3.1 Service models

The identified domains of AYA-friendly primary healthcare services in LMICs are shown in Fig. 2.

3.1.1 Facility characteristics

Among the 40 articles, seven discussed the scope of facility characteristics. In LMICs, facility characteristics have a significant effect on the effectiveness and accessibility of healthcare services for adolescents⁵². The characteristics of the services include a wide range of offerings, ranging from preventive care and immunizations to mental health assistance⁵⁴, meeting the complex and evolving health requirements of adolescents. A well-structured schedule ensures that services are available at times that are convenient for this demographic²⁵ while also acknowledging the special barriers that they may encounter in obtaining healthcare⁴⁸. Adequate infrastructure is critical for providing a suitable environment for healthcare delivery and ensuring that institutions are adequately resourced⁴⁷. The incorporation of evidence-based guidelines and protocols ensures that healthcare practices are based on the most recent scientific findings, ensuring effective and standardized care. Strong referral networks and outreach programs help strengthen the continuum of care by allowing seamless transitions from primary care to specialized services, which is especially important in cases requiring advanced intervention. These facility characteristics¹⁵, taken together, lay the foundation for a responsive, comprehensive, and accessible primary care system adapted to meet the unique healthcare requirements of adolescents in resource-constrained contexts²⁸.

3.1.2 Appropriate package services

Among the 40 articles, 10 discussed appropriate package services. The appropriate package services in primary care play a significant role in meeting the special healthcare needs of this demographic in LMICs, where adolescent health is a critical public health concern¹⁵. Case management ensures that each adolescent’s health is addressed in a comprehensive and personalized manner, coordinating services and treatments to ensure the best possible outcomes¹⁹. Patient-centered care emphasizes the necessity of incorporating adolescents in decision-making, respecting their autonomy, and customizing healthcare treatments according to their preferences and cultural circumstances^43,55. Testing services, including a variety of diagnostic and screening procedures, aid in the early detection and management of health problems^34,55. Telehealth projects broaden the scope of primary care services, eliminating geographical limitations and improving accessibility for adolescents²⁴. Primary preventive strategies emphasize health promotion and education⁴⁵, whereas secondary prevention focuses on early detection and intervention for emergent health risks^32,33. Tertiary prevention targets chronic illnesses and disabilities to reduce their impact. This complete bundle promotes overall well-being and resilience by providing a comprehensive and adaptive approach to adolescent health in resource-constrained settings^43,49.

3.1.3 Provider competencies

Providing competencies in primary care for adolescents in LMICs involves a varying collection of skills and knowledge necessary for providing optimal healthcare⁴². To address the physical, emotional, and social components of this population, health practitioners, including physicians, nurses, and allied health professionals, require specialized training in adolescent health^36,46. Non-health workers, including community health workers and outreach workers, play an important role in linking adolescents to vital services and promoting health education in the community³⁶. Communication, empathy, and cultural competence are all important soft skills^41,46. Providers must successfully engage with adolescents, building their trust and encouraging open communication ^16,18. Understanding adolescents’ social and cultural backgrounds is critical for properly customizing healthcare interventions. The combination of technical expertise, community participation, and soft skills enables practitioners to overcome the challenges of adolescent health in LMICs, providing a holistic and patient-centered approach that addresses this population’s unique needs⁴².

3.1.4 Data and quality improvement

Effective data and quality improvement processes are critical components for improving healthcare outcomes in primary care for adolescents in LMICs. The problem-solving cycle is a methodical strategy for identifying, analyzing, and resolving healthcare difficulties²⁵. Quality assurance and control mechanisms are placed to ensure that healthcare services consistently satisfy the set criteria, fostering dependability and excellence. It is vital to emphasize patient safety, with a focus on minimizing errors and adverse events. Creating a safe work atmosphere encourages healthcare practitioners to report occurrences, learn from mistakes, and continuously improve practices. The incorporation of extensive data and analysis of this framework allows healthcare facilities to identify areas for improvement, track progress, and personalize interventions to target specific needs in adolescent health⁴⁴. Primary care in LMICs can offer adolescents high-quality, safe, and consistently improving healthcare services by combining the problem-solving cycle, quality assurance, patient safety, and safety-oriented work culture.

3.1.5 Adolescent health literacy

Among the 40 papers, 11 mentioned adolescent health literacy as an important part of primary care in LMICs. Adolescent health literacy affects young people’s ability to understand, access, and apply health information to make informed decisions^27,56. Media information is a primary source of health knowledge in many settings, and interventions to increase media literacy can equip adolescents to critically evaluate health-related content³⁸. Information technology, including mobile applications and internet resources, improves access to health information, allowing adolescents to seek help on their own⁵¹. Family literacy programs create a supportive atmosphere by preparing parents and guardians to discuss and guide adolescents on health issues^21,23. Message reminders delivered across multiple communication channels reinforce health messages and promote preventive behaviors^30,51. Creating a completely online platform, including websites and social media, serves as a one-stop shop for trustworthy tools, health, and service information⁴⁰. Stakeholders, such as schools and community leaders, as well as the users themselves, also develop a collaborative approach to smooth out appropriate adolescent health literacy and policies²⁴, ensuring that young people have the knowledge and skills necessary to effectively navigate their health journey³⁹.

3.1.6 Equity and nondiscrimination

The concepts of equity and nondiscrimination are crucial in primary care for adolescents in LMICs to ensure that healthcare services are accessible and acceptable to all, regardless of socioeconomic level, gender, or cultural background³⁵. Acceptance in healthcare indicates that services are culturally appropriate and attentive to the different needs of adolescents, establishing an environment in which young people feel at ease in receiving care. No stigmatizing practices are essential for overcoming societal biases and prejudices that may be barriers to accessing healthcare³⁸. By emphasizing equity, healthcare professionals aim to decrease inequities in access to and quality of treatment across demographic groups, ensuring that every adolescent, regardless of background, receives respectful and inclusive healthcare services. This method not only improves adolescents’ general well-being but also helps to construct a more just and equitable healthcare system in LMICs³⁷.

3.1.7 Community support

Community support is essential for the effectiveness of primary care services for adolescents in LMICs, as it fosters a collaborative approach to addressing the unique healthcare requirements of this demographic group²⁰. Parents and guardians play important roles in establishing a supportive home environment, encouraging health-related communication, and ensuring that adolescents have access to appropriate healthcare services⁵⁶. School health programs are critical venues for health education, screening, and preventive treatment, supporting overall well-being within a learning environment^31,32. Community groups focused on interests and hobbies provide additional opportunities for adolescents to interact with peers and mentors, building a sense of belonging and support that improves their health^22,29. Linking these community networks to the healthcare system offers a smooth connection, allowing adolescents to successfully access primary care services. This collaborative model acknowledges the impact of community dynamics on adolescent health and emphasizes the value of collaborative efforts in delivering complete and accessible primary care services in resource-constrained contexts⁵³.

3.1.8 Adolescent participation

In LMICs, the active engagement of adolescents is a cornerstone of good primary care, recognizing the necessity of involving this group in their own health decisions. Peer groups play an important role in this process, as they provide a safe space for adolescents to discuss their experiences, exchange knowledge, and negotiate complex healthcare issues as a group^50,51. The use of the expertise and insights of AYA becomes essential for adapting healthcare services to this age group’s specific needs and preferences¹⁷. Peer modeling is a useful technique for creating healthy norms and exhibiting excellent health behaviors in a society²². Creating opportunities for peer navigation also encourages adolescents to access and navigate primary care services, ensuring that they feel safe and knowledgeable throughout their healthcare journey²⁹. Primary care at LMICs can build a sense of agency and ownership in adolescents, contributing to improved health outcomes and the development of a more patient-centered approach to adolescent health.

This review provides strategies for a comprehensive model for AYA-friendly primary care services. Our review demonstrated that an effective model of AYA-friendly primary health care services in LMICs is built on strategies in the following three main domains: health facilities, health literacy, and the environment–empowerment.

Health facilities

Adolescents are stereotyped as the healthiest demographic and are frequently excluded from standard healthcare services. The common problem faced by most health facilities is the underutilization of health services by adolescents for many reasons, including a lack of knowledge among adolescents; legal, cultural, and logistical barriers; high costs; and, most notably, poor-quality clinical services and unwelcoming services. The W.H.O introduced criteria for establishing adolescent-friendly services in clinics after recognizing that adolescents have special health needs and encounter numerous barriers to accessing and receiving healthcare. Adolescent-friendly health services are an important method for improving youth health.⁵⁷

The workforce is at the heart of every health system and plays an important role in promoting health. Adolescent health care is provided by a variety of specialists at both the primary and referral levels, and progress towards universal health coverage for adolescents will necessitate a renewed emphasis on education. Training programs must shift from an acute and episodic care model to a chronic and preventive care model, emphasizing the importance of designing competency-based educational programs that emphasize the developmental and contextual aspects of adolescent health and improve competencies in consultation, interpersonal communication, and interdisciplinary care.⁵⁸

Health literacy

Given that health literacy is a broad concept with numerous assessment methodologies, it is important to analyze it in the context of specific material. In the current study, adolescent health literacy was defined as 'an individual ability to discover, comprehend, and use health information and services to improve and maintain good health' and applied to school settings. Schools were chosen because they are essential venues for improving adolescent health literacy via school-based programming.^32,33 Adolescents also spend most of their time in school. Thus, acquiring substantial populations in a brief period is both possible and attainable. ⁵⁹

General literacy (the capacity to read and write short phrases about daily life) is a fundamental skill that allows people to engage more fully in society. There is consistent evidence that low literacy is associated with poor health outcomes. People with lower reading levels are generally 1.5–3 times more likely to have poorer health outcomes than people with greater literacy levels are.⁶⁰

Environment and empowerment

Patient satisfaction, patient loyalty, and healthcare organizations’ productivity and effectiveness are all linked to the quality of care provided. Quality health care is characterized as "providing the right healthcare services in the right way in the right place at the right time by the right provider to the right individual for the right price to get the right results"⁶¹. Adolescent health is greatly supported by peer groups and families, who also have an impact on how young people perceive their subjective well-being and quality of life. ⁶² Behavioral patterns within the family with underlying mechanisms, such as family beliefs and support for healthy lifestyles, are examples of the "family-level" processes. They also demonstrate familial interdependencies and how family members may impact one another's health-related behaviour.⁶³

Relationships with family, classmates, and the community play a crucial role in the development of adolescents, and interactions with others are fundamental to health and well-being. Strengthened adolescents’ mental and emotional wellness is a lifetime benefit of having a supportive social network of parents, friends, and teachers.⁶⁴

AYA have special demands, since they are in the process of forming their identity and attaining autonomy. Their bodies and minds are growing, and this is a time of experimentation with risk-taking and increasing independence. When it comes to advising, preventative, and treatment services, adolescents should have trust in their abilities to obtain primary care services without the assistance of their parents or guardians, when necessary. To deliver the best possible treatment, the primary healthcare system and medical professionals must adapt to current rules and offer a package of services based on client requirements.⁶⁵

A need for measurable standards and quality improvement

To date, many countries have shifted to a standard-driven strategy to increase the caliber of adolescent healthcare by incorporating the abovementioned elements. A wide range of services, including those provided by the government, nongovernmental organizations, and the commercial sector, including primary care, general practice, and community-based services, are the subject of standard development. Nonetheless, standards will be a “living document” that will continue to change as services gradually work to achieve pertinent and expected standards of care. Quality improvement is also acknowledged to be an ongoing effort⁶⁶.

Service standards are meant to serve as a roadmap for any facility trying to increase the quality of adolescent care services, as well as to encourage district- and national-level initiatives to assist the facility in this endeavor. They may need to be modified to reflect the unique characteristics of a single clinic or practice setting, a large hospital, or a health care system because they are designed nationally or occasionally regionally⁴¹. Additionally, the suggested standards and criteria are related primarily to traditional healthcare delivery systems, which might require some adjustments for digital healthcare delivery that are being attempted and implemented more frequently in various nations; that being said, the basic domains of adolescent-friendly healthcare approaches will probably not be altered^24,54.

To better address the demands of adolescent health and development, one aspect of the change health systems must go through: the creation and implementation of national quality standards and monitoring systems¹⁵. It is impossible to successfully increase the standard of care at primary- and referral-level facilities without fortifying health system foundations, which include funding, personnel capacity building, governance, and supply and technology availability⁶⁷. Therefore, to enable healthcare professionals and managers to execute standards and their criteria, national- and district-level actions, in addition to facility- and community-level actions, are required for each health system’s support^15,24.

This scoping review reviewed models of adolescent-friendly healthcare services in various LMICs worldwide, including those in Asian, African, American, and European countries. The representation of countries on the continents mentioned previously is sufficient to provide an overview of the AYA-friendly primary health care services in the LMIC.

Implications for practice

In LMICs, providing AYA-friendly primary healthcare services involves addressing several interconnected variables. AYA health is an important part of community health. Providing health facilities, health literacy, and an environment for AYA-friendly primary healthcare services works together to close these gaps by ensuring accessibility, providing AYA-centric services, maintaining friendly staff, providing education programs, making use of digital health resources, guaranteeing a safe space, involving communities and peers in planning and decision-making, and promoting AYA-friendly policies.

However, further research is warranted to address the feasibility of putting the results of the present review into practice by selecting interventions that are more feasible for pilot implementation purposes.

To develop AYA-friendly primary health care services in LMICs, our scoping review recommends paying attention to the following three domains: health facilities, health literacy, the environment and empowerment. By addressing these aspects collectively, health facilities, health literacy programs, supportive environments, and empowerment initiatives can work synergistically to bridge the gaps in AYA-friendly primary healthcare services in LMICs. This holistic approach considers the unique needs, preferences, and challenges faced by AYA in the context of diverse cultural and socioeconomic situations. However, further research is still needed to address the feasibility of the identified intervention implementation and to pilot it in practice. Model trials are needed to determine the effectiveness of services in increasing the knowledge level and health status of AYA communities.

Author Contributions: Conceptualization: RAW, ISW, DW; Data curation: HMFS, MA; Formal analysis: RAW, HMFS, MA, VSK, ISW; Funding acquisition: ISW, FE, LS; Project administration: ISW, RAW, LS; Methodology: RAW, ISW, MA; Software: RAW, HMFS; Supervision: RAW, ISW; Validation: RAW, ISW; Visualization: HMFS; Writing original draft: RAW, MA, VSK, HMFS, DW; Writing (review & editing): All authors.

Funding: The collaboration was funded by the Lembaga Pengelola Dana Pendidikan (Indonesian Endowment Fund for Education) in agreement with the Indonesian Ministry of Education, Culture, Research, and Technology and managed by Universitas Indonesia under the PRIME Program (Grant No. NKB-11/UN2.RST/HKP.05.00/2023).

Data availability statement: The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials.

Acknowledgments: This study is part of the “Strengthening Adolescent and Young Adult-friendly Primary Care Service within university clinics in Indonesia” (STRAYA INDO) project, which is a collaboration project of Universitas Indonesia, Universitas Gadjah Mada, and Universitas Airlangga with Melbourne University, Australia.

Conflicts of interest: The authors declare that they have no conflicts of interest.

Declaration of generative AI in scientific writing statements: During the preparation of this work, the author(s) used ‘Chat GPT’, ‘Grammarly’, and ‘Quill Bot’ to sharpen and clarify the language because English is not our first language. After using these tools/services, the author(s) reviewed, paraphrased, and edited the content as needed and take(s) full responsibility for the content of the publication.

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No competing interests reported.

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Adolescent and Young Adult-Friendly Primary Health Care Services in Low- and Middle-Income Countries: A Scoping Review

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Abstract

Figures

1. Introduction

2. Materials and methods

3. Results

3.1 Service models

3.1.1 Facility characteristics

3.1.2 Appropriate package services

3.1.3 Provider competencies

3.1.4 Data and quality improvement

3.1.5 Adolescent health literacy

3.1.6 Equity and nondiscrimination

3.1.7 Community support

3.1.8 Adolescent participation

4. Discussion

5. Conclusions

Declarations

References

Additional Declarations

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Version 1