http://orcid.org/0000-0002-2006-6539
Figures
Abstract
Background
The need to address sexual and reproductive health and rights (SRHR) in humanitarian settings is more urgent than ever, especially among young refugees. We conducted a scoping review to identify and synthesise the literature on perceived barriers and facilitators to SRHR among young refugees and interventions created to address their needs.
Methods
We searched three databases (PubMed, Global Health and POPLINE) for peer-reviewed and grey literature published in English between January 2008 and June 2018 that reported on SRHR barriers, facilitators and interventions for young refugees aged 10 to 24 years. We extracted data using standardised templates and assessed the quality of studies according to study design. Data were charted using qualitative content analysis and organised in line with a socio-ecological framework (individual, social and community, institutional and health system, and structural).
Findings
We screened 1,169 records and included 30 publications (qualitative, quantitative, and mixed methods) across 22 countries; 15 were peer-reviewed articles and 15 were from the grey literature. Twenty-two publications reported on young people in refugee camps or alternatives to camps (e.g. sustainable settlements), and eight referred to young refugees who had been resettled to a third country. We identified 19 sub-categories for barriers and 14 for facilitators at the individual, social and community, institutional and health system, and structural levels. No publications discussed the SRHR challenges faced by young homosexual, bisexual, transgender or queer refugees, or those living with HIV. Nine publications described interventions, which tended to focus on the provision of SRHR services and information, and the training of peers, parents, religious leaders and/or service providers.
Conclusions
Findings highlight that while young refugees experience similar barriers to SRHR as other young people, many of these barriers are exacerbated by the refugee context. The limited number of publications and evidence on interventions underlines the immediate need to invest in and evaluate SRHR interventions in refugee contexts.
Citation: Tirado V, Chu J, Hanson C, Ekström AM, Kågesten A (2020) Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review. PLoS ONE 15(7): e0236316. https://doi.org/10.1371/journal.pone.0236316
Editor: Catherine S. Todd, FHI360, UNITED STATES
Received: October 21, 2019; Accepted: July 4, 2020; Published: July 20, 2020
Copyright: © 2020 Tirado et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Universal access to sexual and reproductive health (SRH) is a fundamental human right that is central to achieving the 2030 Agenda, as emphasised in the Sustainable Development Goals related to good health and wellbeing, and gender equality [1]. Young people aged 10 to 24 years lie at the very heart of sustainable development, both as agents of change to achieve healthy, inclusive and stable societies, and because they are the ones most affected by impacts related to climate change, gender equality, poverty, conflict, and migration [2]. Yet, the sexual and reproductive health and rights (SRHR) of young people, who today account for 24% of the world’s population at 1.8 billion, are frequently overlooked [3, 4].
The need to address the SRHR of young people in humanitarian contexts is especially pressing. As of 2019, an estimated 70.8 million people had been forcibly displaced worldwide; of those, around 25.9 million were refugees and over half were under the age of 18 [5]. Evidence shows that refugee adolescents (10–19 years) and youth (15–24 years) often face challenges in accessing SRHR information and services due to the poor living conditions, inadequate sanitation and limited access to health services associated with conflict and displacement [6, 7], in addition to the stigma associated with sexual activity at a young age [8]. Experiences of forced migration may further impact young people’s power and agency to negotiate and make decisions related to their bodies and sexual relationships, thereby putting them at risk of sexual violence, HIV and other sexually transmitted infections (STIs), unintended pregnancies, unsafe abortions and preventable maternal deaths [9, 10]. For example, a systematic review found that refugee, migrant and internally displaced girls and young women in Africa commonly lack access to SRH information, while simultaneously facing high risk of gender-based violence (GBV) including sexual violence [8]. In addition, while in transit and upon reaching a host country, young refugees are met with new cultural, social and legal contexts [11, 12]. This is exemplified by a qualitative study which found that Afghan refugee women who had settled in California experienced cultural conflict between the traditional emphasis placed on family in their home country, versus the more liberal values held by their host country [13].
In order to improve SRHR and identify tailored interventions in the context of conflict and displacement, there is an urgent need to gather information to ensure that the needs of young refugees are respected, protected and fulfilled in line with international human rights standards [14, 15]. The available literature tends to report on the SRHR needs of young people [16–18], the SRHR needs of refugees in general [19–23], or the SRHR needs of a broader population such as refugee, migrant and internally displaced young women in Africa [8]; however, there is limited information available on the SRHR of young refugees [8, 24, 25]. To our knowledge, no study has compiled the global evidence on barriers and facilitators to SRHR for refugees aged 10 to 24 years.
To close this gap, we reviewed and synthesised the literature on perceived barriers and facilitators to SRHR among young refugees globally, and the interventions developed to address their needs. We focused on two central research questions:
- What has been reported on the perceived barriers and facilitators to SRHR for young refugees worldwide?
- What has been reported on current SRHR interventions that target young refugees?
For the purpose of the current review, we use the term ‘refugee’ to refer to any person who has undergone forced international migration, including asylum seekers. Different sub-populations of refugees (e.g. victims of trafficking) face different risks and challenges associated with their specific migration process and context–whether they are in transit, being resettled to a new country or voluntarily repatriating. Throughout this scoping review, we differentiate between refugees residing in camps or alternatives to camps, and refugees who have been resettled to a third country. In line with classifications used by UNHCR, the former is used in this review to group publications that report on refugees living in camps and spontaneous settlements, as well as those who have alternative arrangements, such as urban refugees living independently amongst host populations [26]. In refugee camps and spontaneous settlements, people tend to live in temporary shelters that can create challenges for their health, such as overcrowding and increased exposure to health hazards and violence. Alternatives to camps are diverse and depend on the host country’s context, but are intended to be sustainable solutions that ensure refugees are assisted and protected [26]. Also in line with classifications used by UNHCR, the latter grouping includes publications on refugees who have been granted permanent settlement in a third country, typically as part of UNHCR’s resettlement programme. Resettlement countries include the United States, Canada, Germany, the United Kingdom, Australia and the Nordic countries [27].
Conceptual framework
We referred to a model by Kaufman et al. [28] when developing a socio-ecological framework to guide our review, including the data charting and organisation of results. Building on Bronfenbrenner’s ecological systems theory [29], our framework illustrates how a combination of individual (e.g. beliefs, behaviours), social and community (e.g. norms), institutional and health system (e.g. health services, education), and structural (e.g. laws, protection mechanisms) factors interact to shape health and wellbeing among young refugees.
Methods
We conducted a scoping review, exploring both quantitative and qualitative publications, to achieve our aim. Scoping reviews have become increasingly popular in health research given their usefulness for mapping the range and nature of evidence in relation to complex topics and for identifying gaps in the literature [30, 31]. They are particularly relevant for examining emerging evidence on a topic and may act as precursors for more rigorous systematic reviews. We followed the guidelines for conducting a scoping review outlined by Arksey and O’Malley [32], Levac, Colquhoun and O’Brien [33] and the Joanna Briggs Institute [34]. The initial methods for screening, study selection and data charting were outlined in an unregistered protocol (S1 Appendix). The review was structured in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews checklist (S2 Appendix).
Eligibility criteria
We considered primary research studies of all designs as well as grey literature across all geographical regions; reviews were excluded as they did not add new primary data. In order to be included, studies had to meet the following inclusion criteria (S3 Appendix):
- published in the English language;
- published between 2008 and 2018, given the most recent increase in international migrants during this time period;
- focus on young people between 10–24 years of age: ‘adolescents’ (10-19-year-olds), ‘youth’ (15-24-year-olds), or people across these age brackets [35];
- focus on refugees (defined as those who have moved from one country to another to seek international protection, including asylum seekers and refugees who have fled their country of origin and are unable or unwilling to return because of well-established fear of persecution) [36]; and
- report on perceived SRHR barriers, facilitators and/or interventions.
Accordingly, studies were excluded if they focused on internal migrants, such as rural-urban migrants, or migrant workers. Publications that presented data for young people plus other age groups, or refugees plus nationals, were only included if data were disaggregated by population.
Information sources and search
We searched the peer-reviewed literature in two databases (PubMed and Global Health) and grey literature in one database (POPLINE) from 1 January 2008 to 15 February 2018. Our search strategy was built in four steps using free-text and controlled vocabulary (e.g. MeSH terms): 1) sexual and/or reproductive health and rights (e.g. "sexual health" OR "sexual rights" OR "reproductive health" OR "reproductive rights") AND barriers and/or facilitators including interventions (e.g. barrier* OR facilitator* OR intervention*) AND young people (e.g. adolescent* OR young OR youth) AND refugee (e.g. refugee* OR "asylum seekers") (S4 Appendix). The search strategy was adapted for each database (S5 Appendix). We also hand-searched the websites of six organisations working with SRHR in humanitarian contexts: UNFPA, WHO, UNICEF, Guttmacher Institute, Women’s Refugee Commission and Plan International, in addition to the reference lists from all included publications. The six international organisations were selected for hand searching as they were known to the authors as having engaged in research and advocacy for SRHR and/or in humanitarian settings. These particular organisations were selected to augment the collection of papers identified by the electronic searches.
After the initial database searches, we reviewed the abstracts to identify the most common and relevant keywords; these included ‘sociocultural’, ‘planning’, ‘teenage’ and ‘resettlement’. We then performed a second search across all included databases using the original search strategy plus the identified keywords. In addition, we conducted a third search in June 2018 to check for any newly published articles. In February 2020, we re-conducted the original PubMed search and removed filters that relied on publications having been indexed with MeSH terms by PubMed (e.g. Humans), to enable publications that had not yet been indexed to be included.
Selection of sources of evidence
We imported all records into an online article management application [37] and removed all duplicates. Two authors (JC and VT) screened the titles and abstracts of all records using a 7-item screening process (S6 Appendix). Publications that passed the initial screening were subjected to full-text review. Disagreements at any stage were resolved by consensus or by a third member of the research team. We extracted data using a standardised 27-item template to capture information about the study characteristics (e.g. publication year, country of origin, host country, study population, study aim, design), reported barriers and facilitators, and intervention characteristics (e.g. setting, activities) if applicable (S7 Appendix).
Data charting process
We conducted a charting process to sort and organise the included publications and elicit information and insights relevant to our review, focusing on the study region, setting, sample size and participants. Findings were analysed using qualitative content analysis and synthesised using a thematic, narrative approach [38, 39]. Specifically, we identified and extracted meaning units from the results sections of the publications, and employed an abstraction process to develop codes, sub-categories and categories (S8 Appendix). In the case of any overlap between grey literature and peer-reviewed publications, we only extracted information once to prevent duplication of the same data, and documented which publications originated from the same project. We initially used an inductive approach, where we examined the text without predetermined keywords or categories [40]. We then applied a more deductive approach, where we linked the codes that had emerged to the different levels of the socio-ecological model [28]. For qualitative studies, quotations were extracted to provide examples for each code. Sub-analyses by age and sex were not possible due to the lack of disaggregated data; we therefore reported findings for the broader group of young refugees.
Critical appraisal of individual sources of evidence
We conducted a critical appraisal to assess the quality of all included primary studies. Two authors (JC and VT) independently assessed the quality of all included publications according to study design, using the Cochrane Collaboration Qualitative Methods Group’s criteria for the critical appraisal of qualitative research [41] and the Effective Public Health Practice Project’s Quality Assessment Tool [42] for any quantitative sections. These tools allowed us to examine the appropriateness of each study’s aim, methodology, design and reported findings; discrepancies about quality were discussed until a consensus was reached. Ethical approval was reported by 23 out of the 30 included publications. The remaining seven publications did not provide information on ethical approval. Of the five publications that were rated to be low quality in the qualitative appraisal, four publications did not provide information on ethical approval.
Results
Fig 1 shows the results from the searches, title and abstract screening and full-text review. In total, 1,169 records were identified across the peer-reviewed and grey literature. After the removal of duplicates, 1,072 records underwent title and abstract screening, resulting in 74 full-text publications to be assessed for eligibility. The main reasons for exclusion during the full-text reviews were lack of disaggregated results (20 publications), wrong study population (13 publications), lack of in-depth discussion on SRHR barriers, facilitators or interventions (10 publications), and published outside of the date restriction (1 publication). Finally, 30 publications [43–72] were included for data extraction and synthesis.
Characteristics of the included publications
Table 1 shows the characteristics of the 30 included publications [43–72], of which 15 were from the grey literature [44, 45, 50, 51, 60–66, 69–72] and 15 were from peer-reviewed journals [43, 46–49, 52–59, 61, 67, 68]. A number of publications came from the same broader research project or study (Table 1). All of the included publications reported on barriers and/or facilitators to SRHR, while 9 out of the 30 publications [50, 51, 61, 63, 65, 68–71] also reported on interventions conducted to improve SRHR among young refugees.
Twenty publications employed a qualitative study design, nine employed mixed methods, and one employed a quantitative design. Study settings included, but were not limited to, Australia (6 publications) [46, 53–57], Kenya (5 publications) [45, 50, 64, 67, 68], Uganda (5 publications) [45, 51, 66–68], Ethiopia (5 publications) [49, 59, 62, 69, 72], and Tanzania (4 publications) [50, 60, 61, 70]. Sample populations included, but were not limited to, refugees from Sudan, the Democratic Republic of Congo, Somalia, Burundi, Iraq and Bhutan.
Twenty-three publications reported on studies conducted with both males and females, while seven were specific to females; no publications referred only to young male refugees. Half (15 publications) described studies with youth aged 15 years and above, and the other half also included younger adolescents (10 to 14 years); however, very few presented results disaggregated by age. In terms of the migration context, we found that 22 publications focused on young people living in refugee camps or alternatives to camps [43–45, 47, 49–51, 58–72] and 8 publications referred to young refugees who had been resettled to a third country [46, 48, 52–57].
During the critical appraisal of the qualitative content, 10 publications were rated as high quality, 15 publications were rated as moderate quality, and 5 publications were rated as low quality in line with the Cochrane Collaboration Qualitative Methods Group’s criteria (S9 Appendix). Of the 11 publications that also reported quantitative data (including mixed methods), none were rated as strong against the Effective Public Health Practice Project’s Quality Assessment Tool criteria, two publications were rated as moderate, and nine publications were rated as weak.
Barriers and facilitators for the SRHR of young people in refugee contexts
Fig 2 presents the identified barriers and facilitators in line with the different levels of the socio-ecological framework. Out of the 30 publications, 27 referred to the individual level (e.g. comprehension, perspectives, skills and empowerment), all 30 referred to the social and community level (e.g. relationship power and expectations, GBV, norms), 27 referred to the institutional and health systems level (e.g. basic principles, services, provider support, education), and 23 referred to the structural level (e.g. infrastructure and security, policies and laws, enforcement of laws). For the purpose of clarity, we differentiate between studies conducted with young refugees in camps or alternatives to camps, versus those conducted with young refugees who had been resettled to a third country.
Tables 2 and 3 each present an overview of the barriers and facilitators, respectively, arranged in line with each level of the socio-ecological framework, along with quotations from the included primary studies.
Refugee camps or alternatives to camps
Individual.
Ten publications reported comprehension of SRHR as both a barrier and a facilitator [44, 46, 47, 49, 51, 53, 67, 69, 72]. For example, one publication described linguistic barriers, including a lack of sign interpreters, faced by adolescent males and females in a Kenyan refugee camp [64]. Another study conducted with young females in two Thai refugee camps found that many lacked knowledge about menstruation and the fact that first sex could result in pregnancy [43, 72].
Four publications highlighted the role of skills and empowerment for young people in camps [43, 64, 67, 71]. For example, a qualitative study conducted in a Zimbabwean refugee camp found that young refugees aged 10 to 17 years used protection strategies such as moving in groups [71]. In addition, adolescents with disabilities in a Kenyan refugee camp requested to be taught empowerment-based activities to increase their autonomy and decision-making in relation to SRHR [64].
Six publications reported on risk-taking behaviours in refugee camps [43, 45, 51, 58, 60, 62], such as not using condoms to prevent STIs and unintended pregnancies, due to financial reasons and lack of decision-making power [45, 58]. One publication from Uganda reported on young female refugees engaging in transactional sex to support basic needs, including medical treatment and school fees [51]. Another study conducted in a Malawian refugee camp found that parents encouraged their children to practice transactional sex with older men in exchange for goods or money [71].
Social and community.
Fourteen publications reported that GBV, including sexual harassment, sexual violence, forced sex, home invasion and rape, exploitation and discrimination occurred frequently in camps and alternatives to camps [43, 44, 47, 51, 59–64, 66, 69, 71, 72]. For example, a mixed methods study conducted in a Ugandan refugee camp described how girls faced high risk of sexual violence while travelling to and from school and the market [51]. Interviews with men and boys from the same camp revealed that sexual harassment often occurred due to male “idleness and boredom”. The same Ugandan study also highlighted the role of relationship power and expectations, where teachers in a refugee camp abused their authoritative role by requesting sexual favours of girls and using corporal punishment if they refused [51]. Thirteen studies identified lack of social support and trust as a barrier to SRHR [43, 47, 49, 51–55, 57, 58, 67, 70, 71], for example, a grey report from a Tanzanian refugee camp that described male teachers accusing girls of lying about menstrual cramps [70].
In terms of facilitators, three studies conducted in Tanzanian and Ethiopian refugee camps identified the value of supportive community organisations for SRHR. In particular, training of community leaders on child protection and confidentiality for survivors of GBV was considered a facilitator [59, 60, 62]. Three studies conducted in Ethiopia, Lebanon, Uganda and Tanzania also recommended working with parents and teachers to discuss issues such as menstrual hygiene management and the prevention of child marriage [61, 69, 72].
Institutional and health system.
Two studies reported lack of confidentiality and adolescent-friendly health services as barriers to SRHR [51, 53]. For example, a study in a Ugandan refugee camp noted that while antenatal, mental health and HIV-related services were available, these services were not designed for young people, which discouraged them from utilising services and confiding in providers [45]. Publications also recommended increased privacy and confidentiality [45, 60, 62, 71], employing interpreters [71], and ensuring age-appropriate services (e.g. access to contraception) [60] in a safe space [62] as potential facilitators. Ten studies conducted in countries such as Kenya, Ethiopia and Nepal further identified provider support and tools as facilitators to SRHR [44, 47, 48, 50, 53, 62–65, 69], including the training of health service providers to respond to the specific SRHR needs of young refugees with disabilities [64].
Structural.
Twelve publications reported that inadequate infrastructure and security were barriers to young refugees’ SRHR when residing in refugee camps or alternatives to camps [44, 47, 51, 58–60, 62, 64, 69–72]. Examples included insecure shelters, lack of lighting [62], unsafe latrines [64], lack of water, sanitation and hygiene, and lack of access to menstrual hygiene management facilities in camps and schools [70]. In addition, five publications that examined refugee camps in sub-Saharan Africa reported that young refugees, particularly girls, felt unsafe outdoors when collecting firewood and water, noting lack of adequate policing [51, 60, 62, 69, 71].
Correspondingly, 10 publications discussed effective camp management as a key facilitator for SRHR [46, 51, 60–62, 64, 65, 69–71]. For example, the provision of adequate lighting [51, 62], increased security [51, 60, 62, 71], prevention of alcohol and marijuana use [71], ensuring latrines and houses have sturdy doors and secure locks [62, 64], and building of female-friendly latrines (i.e. with buckets for menstrual hygiene management) in schools, around the camp and in the dwellings of single girl-headed households [62, 70]. It was also suggested that charcoal be distributed throughout the camp to ensure children would not have to collect firewood alone and risk exposure to violence and abuse [71].
Finally, six studies in different refugee camps reported structural regulations such as public policy and laws [51, 62], political context and priorities [53, 56, 62, 68] and lack of law enforcement [62, 71] as barriers to SRHR. For example, a study conducted in a Zambian refugee settlement found that children did not feel comfortable reporting GBV to the police or church due to fear of being sexually assaulted by both [71]. Other barriers included restricted access to contraception for unmarried adolescent refugees [68] and the illegal status of abortion services in Uganda [51].
Resettled to a third country
Individual.
Similar to what was found in refugee camps, nine publications reported low awareness of SRHR among refugees who had been resettled to a third country such as Australia or the United Kingdom [46, 52–57]. Three publications reported that young refugees only received SRHR information for the first time after having contracted an STI or becoming pregnant after resettling in Australia [46, 55, 56]. One publication reported on language barriers in the new country as a barrier to SRHR [53].
Three publications identified poor risk perceptions and misunderstandings as key barriers to SRHR for refugees who had been resettled [46, 54, 56]. For instance, in Australia, many refugees did not see themselves at risk of HIV, as they thought the health screening process prior to entry to the country prohibited the admission of any people with HIV. Furthermore, while HIV was regarded as terminal, many young refugees did not consider it a health concern in Australia [56]. Similarly, another Australian study conducted with resettled young refugees found that many young women expressed fear over abortions due to knowledge about unsafe procedures that had occurred in refugee camps while they were in transit [57].
Social and community.
Two publications that studied resettled young refugees identified a disparity between the norms of a refugee’s country of origin and the norms of their host country [46, 56], for example, parents reported being worried about the liberal norms and values in Australia and associated SRHR knowledge with promiscuity [46, 56]. Parents also expressed concerns about the content included in sexuality education curricula [50]. These differing sociocultural beliefs around SRHR resulted in intergenerational conflict within families [48].
In line with this, twelve publications described how addressing sociocultural norms [43, 46, 47, 53, 56, 59, 70] and improving communication between young people and parents [46, 47, 60, 62, 69, 70] can facilitate the SRHR of young refugees. For instance, an open attitude towards talking about sex assisted young people and their families to navigate the differing sociocultural attitudes they faced after resettling in Australia, thereby reducing some of the intergenerational confusion and conflict [46, 53]. Similarly, one publication that studied African-born refugees in the United States recommended the engagement of parents, community and religious leaders to assist with HIV-prevention efforts [48].
Institutional and health system.
A lack of provider support was identified as a barrier by young refugees who had been resettled to Australia and the United Kingdom [52, 53]. For example, young pregnant women reported that they encountered stereotyped judgements from health professionals in the United Kingdom, which made them feel like they were not in control of their childbirth [52]. Provider support and tools were identified as facilitators by young refugees who had been resettled to Australia and the United States [48, 53], including the support of doctors and other health providers in providing information on SRH [53]. In addition, one publication from Australia emphasised that sexual health education for refugees needs to be interactive, using activity-based learning [53].
Structural.
Three publications reported that refugees felt constrained by resettlement needs such as finding housing, a job and navigating their new society, and therefore could not prioritise their health, including SRH [51, 53, 56]. However, social media and technology were reported as facilitators in one publication on Sudanese refugees who had been resettled to Australia as they found these communication channels to be safe, confidential sources of sexual health information [46].
Interventions for the SRHR of young people in refugee contexts
In addition to describing facilitators and barriers, nine publications also reported on specific interventions to improve SRHR among young refugees [50, 51, 61, 63, 65, 68–71]. Table 4 presents a detailed overview of these interventions according to the type of intervention, setting, population, outcome and methods. Overall, interventions tended to be educational projects within refugee camps aimed to teach young people about SRHR, in addition to projects that involved the sensitisation or training of peer educators, religious leaders, parents and service providers [50, 65, 69, 71]. For example, a school-based intervention in a Rwandan refugee camp used weekly educational sessions facilitated by community health educators on reproductive health at primary and secondary schools. By expanding the community health educators’ role to counsel adolescents on family planning, the communities’ comfort and acceptance of the programme was improved [65]. Another intervention trained 60 young men to identify, address and prevent GBV because they were considered to be more receptive than older men to learn about GBV and address gender norms [50].
Discussion
To the best of our knowledge, this scoping review is the first to map what has been reported on perceived barriers and facilitators, as well as interventions, related to SRHR for young refugees at a global level. We found that most publications reported on barriers, rather than facilitators, including lack of knowledge and information, GBV, sociocultural norms, stigma and shame, lack of social support, and lack of infrastructure and security.
At first glance, many of these barriers to SRHR are similar to those faced by other young people, including stigma and shame surrounding young people’s sexual activity [43, 44, 48, 51, 53, 58, 61, 62, 64, 65, 68, 70], lack of adolescent-friendly services [4] and the importance of confidentiality [24, 73–75]. However, our review indicates that many barriers are exacerbated by the refugee context. Deficiencies in infrastructure and security (e.g. insecure shelters, lack of lighting, unsafe latrines), financial dependency, poor awareness of SRHR and lack of protection for unaccompanied minors, likely increase the risk of sexual abuse, exploitation and other types of GBV. Poor infrastructure for water, sanitation and hygiene, and lack of confidential, respectful and adolescent-friendly SRH services in many refugee camps and alternatives to camps also limit young people’s access to menstrual hygiene, contraception, STI prevention, SRH care and support.
However, not all publications evaluated or identified facilitators or interventions in relation to the reported barriers. While the most commonly reported facilitators (e.g. social support and trust, provision of appropriate services, provider support and tools, improved safety) directly tackle some challenges, we did not identify any facilitators to address peer pressure, social exclusion or stigma for young refugees. In particular, very few studies addressed conflicting sociocultural beliefs related to individual versus family norms which can play a central role when young people transition through puberty and adolescence [7, 76], leaving a gap in the literature.
Only nine publications described SRHR interventions for young refugees [50, 51, 61, 63, 65, 68–71], with most involving service provision and/or training of youth, peer educators, parents, community members, religious leaders and providers (e.g. GBV prevention and response). While an assessment of the evidence and effectiveness of these interventions is beyond the current scoping review, we found that all interventions identified were only conducted in refugee camps or settlements in countries such as Nepal, Tanzania and Uganda. While the under-reporting of interventions is possible, this still indicates that more research is needed on what types of interventions are most beneficial for different groups of young refugees across different contexts.
Young refugees are a highly heterogeneous population–yet, most publications did not present disaggregated data by characteristics such as age, sex, sexual orientation, race/ethnicity, socioeconomic background or physical and psychological impairments. Four publications specifically referred to young refugees with disabilities [63, 64, 66, 67], noting the importance of training service providers on how to respectfully communicate with these refugees and understand and meet their SRHR needs. While a lack of disaggregated data is not unique to refugee populations, such data is critical to understand and tailor programs to meet the needs of underrepresented sub-groups. In particular, we found no publications on young lesbian, gay, bisexual, transgender, queer or intersex refugees, despite the fact that this population faces a disproportionately high risk of HIV and STIs due to stigma, legal context, financial vulnerability, poor mental health and lack of services [77].
Furthermore, we found that little attention is given to the sexual and reproductive rights of young refugees in the literature. While several publications focus on GBV, few discuss sexual rights including an individual’s right to choose if, when and with whom to be in a relationship and have sex, as well as reproductive rights related to abortion. This conclusion is supported by Hartmann et al. who found that while many SRH interventions address gender inequalities, very few involve rights [78]. As suggested by Orza et al., the lack of a rights-based approach in interventions may be because many of these rights, sexual rights in particular, have not been recognised in international human rights conventions and in the Sustainable Development Goals, which could reinforce underlying inequalities [79]. From a life course perspective, it is critical to prioritise young refugees’ sexual and reproductive rights through adolescence and into adulthood as denial of these rights will put them at high risk of GBV, unintended pregnancies, unsafe abortions, and preventable maternal deaths. Interventions should focus on building capacity among local actors and authorities, including camp health service providers, community leaders and young people themselves so they are able to support and protect the lives, health and dignity of girls, boys and non-binary individuals in refugee contexts.
Strengths and limitations
This scoping review highlights SRHR barriers and facilitators for young refugees globally and identifies major research gaps. Key strengths include: the scoping approach, which allowed the mapping of literature across different countries and refugee contexts while drawing on diverse methodologies; the fact that most data came from young refugees themselves; the use of the socio-ecological framework to synthesise the data; the critical appraisal of all primary studies; and the presentation of findings by type of refugee context (i.e. camps or alternatives to camps versus resettled to a third country). Our aim was to establish a knowledge base and identify knowledge gaps, rather than merely comparing and contrasting findings across different settings. Even though we strived for a comprehensive search, it is possible that we missed relevant studies as we restricted the review to publications written in English within the last 10 years. During initial revisions of the manuscript, we noted that the inclusion of certain filters (e.g. Humans) in the original PubMed search resulted in the omission of publications that had not yet been indexed. We therefore removed the filters and re-conducted the original PubMed search with the same date restrictions, resulting in the inclusion of five additional publications. Furthermore, few publications reported results disaggregated by age and sex, undermining efforts to conduct stratified analyses to better understand the needs of specific sub-groups. Finally, due to the cross-sectional design of many studies, it is possible that some of the reported barriers and facilitators to SRHR were experienced before the study participants became refugees.
Our review identified several avenues for future research, such as institutional and structural facilitators (e.g. health services, the role of laws and policies) for resettled young refugees where literature is currently missing. In addition, further research could differentiate between experiences faced by younger versus older adolescents, and males versus females to support age and gender perspectives in analyses. More evidence is needed on facilitators and effective interventions, particularly for young refugees who have been resettled. Future research could also investigate whether any of the identified barriers, facilitators or interventions are applicable in refugee settings other than those included in the current review. In addition, as no publications reported on SRHR barriers and facilitators for young lesbian, gay, bisexual, transgender, queer or intersex refugees, this points to a large gap in the literature to be addressed in future studies and interventions.
Conclusions
In the foreseeable future, war and civil unrest, poverty and climate change will continue to forcibly displace people from their countries of origin. Our results highlight that young refugees are among the world’s most vulnerable populations and have specific SRHR needs. While they experience similar barriers to SRHR as other young people, many of these are exacerbated by the refugee context, such as the high risk of sexual abuse and exploitation as well as other forms of GBV. It is crucial that effective interventions are implemented to improve SRHR outcomes for all refugees, with a particular focus on the safety and security of young people. Addressing these needs will help young men, women and non-binary individuals in refugee contexts to live healthy and productive lives now and in the future. Despite international commitments to ensure young refugees’ SRHR, such as the Global Strategy for Women’s, Children’s and Adolescents’ Health, few interventions actually address their specific needs–calling for further investment and commitment from the global health community to strengthen and protect the SRHR of young people in refugee contexts.
Supporting information
S2 Appendix. PRISMA extension for scoping reviews checklist.
https://doi.org/10.1371/journal.pone.0236316.s002
(PDF)
S5 Appendix. Full search strategy used for the ‘Global Health’ electronic database.
https://doi.org/10.1371/journal.pone.0236316.s005
(PDF)
S6 Appendix. 7-item form for the screening process.
https://doi.org/10.1371/journal.pone.0236316.s006
(PDF)
S7 Appendix. 27-item template for data extraction.
https://doi.org/10.1371/journal.pone.0236316.s007
(PDF)
S9 Appendix. Critical appraisal of included publications.
https://doi.org/10.1371/journal.pone.0236316.s009
(PDF)
Acknowledgments
The authors would like to thank Nora Piay Fernández for her support with reviewing and extracting data during the updated search process.
References
- 1. Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet. 2018;391(10140):2642–92. Epub 2018/05/14. pmid:29753597
- 2.
United Nations. Youth and the 2030 Agenda for Sustainable Development [Internet]. 2018 [cited 2019 Sep 29]. https://www.un.org/development/desa/youth/world-youth-report/wyr2018.html.
- 3.
Woog V, Kågesten A. The Sexual and Reproductive Health Needs of Very Young Adolescents Aged 10–14 in Developing Countries: What Does the Evidence Show? 2017. https://www.guttmacher.org/report/srh-needs-very-young-adolescents-in-developing-countries.
- 4. Chandra-Mouli V, Svanemyr J, Amin A, Fogstad H, Say L, Girard F, et al. Twenty years after International Conference on Population and Development: where are we with adolescent sexual and reproductive health and rights? J Adolesc Health. 2015;56(1 Suppl):S1–6. Epub 2014/12/23. pmid:25528975
- 5.
United Nations High Commissioner for Refugees, UNHCR. Figures at a Glance—Statistical Yearbooks [Internet]. 2019. https://www.unhcr.org/figures-at-a-glance.html.
- 6.
United Nations Population Fund, UNFPA. International Conference on Population and Development (ICPD) [Internet]. UNFPA. 1994 [cited 2019 Jul 25]. https://www.unfpa.org/events/international-conference-population-and-development-icpd.
- 7.
Janssens K, Bosmans M, Temmerman M. Sexual and Reproductive Health and Rights of Refugee Women in Europe [Internet]. 2005 [cited 2019 Sep 29]. https://biblio.ugent.be/publication/343666/file/704599.
- 8. Ivanova O, Rai M, Kemigisha E. A Systematic Review of Sexual and Reproductive Health Knowledge, Experiences and Access to Services among Refugee, Migrant and Displaced Girls and Young Women in Africa. Int J Environ Res Public Health. 2018;15(8). Epub 2018/07/28.
- 9.
International Planned Parenthood Federation. Champions for sexual and reproductive health and rights [Internet]. 2017 [cited 2019 Sep 4]. https://ippfen.org/sites/ippfen/files/2017-12/WHOWEARE_PagebyPage.pdf.
- 10.
United Nations Population Fund. The State of World Population 2017—Worlds Apart: Reproductive Health and Rights in an Age of Inequality [Internet]. 2017 [cited 2019 Sep 17]. https://www.unfpa.org/press/state-world-population-2017.
- 11.
International Organization for Migration, IOM. International Migration, Health and Human Rights [Internet]. 2013 [cited 2019 Sep 4]. http://publications.iom.int/system/files/pdf/iom_unhchr_en_web.pdf.
- 12. Gushulak B, Weekers J, Macpherson D. Migrants and emerging public health issues in a globalized world: threats, risks and challenges, an evidence-based framework. Emerg Health Threats J. 2009;2:e10. Epub 2009/01/01. pmid:22460280
- 13. Lipson JG, Miller S. Changing roles of afghan refugee women in the United States. Health Care for Women International. 1994;15(3):171–80. pmid:8002414
- 14.
United Nations General Assembly U. Convention relating to the status of refugees 1951 [cited 189]. 137]. https://www.unhcr.org/5d9ed32b4.
- 15.
United Nations Committee on Economic SaCR, CESCR. The Right to the Highest Attainable Standard of Health 2000. https://www.refworld.org/pdfid/4538838d0.pdf.
- 16. Capurchande R, Coene G, Schockaert I, Macia M, Meulemans H. "It is challenging … oh, nobody likes it!": a qualitative study exploring Mozambican adolescents and young adults’ experiences with contraception. BMC Womens Health. 2016;16:48. Epub 2016/08/01. pmid:27475909
- 17. Regmi P, Simkhada P, Van Teijlingen ER. Sexual and reproductive health status among young peoples in Nepal: opportunities and barriers for sexual health education and services utilization. Kathmandu Univ Med J (KUMJ). 2008;6(2):248–56. Epub 2008/09/05.
- 18. Lopez JR, Mukaire PE, Mataya RH. Characteristics of youth sexual and reproductive health and risky behaviors in two rural provinces of Cambodia. Reprod Health. 2015;12:83. pmid:26346936
- 19. Khawaja M, Hammoury N. Coerced sexual intercourse within marriage: a clinic-based study of pregnant Palestinian refugees in Lebanon. Journal of midwifery & women’s health. 2008;53(2):150–4.
- 20. Keygnaert I, Vettenburg N, Temmerman M. Hidden violence is silent rape: sexual and gender-based violence in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Cult Health Sex. 2012;14(5):505–20. Epub 2012/04/04. pmid:22468763
- 21. Yelland J, Riggs E, Wahidi S, Fouladi F, Casey S, Szwarc J, et al. How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families? BMC pregnancy and childbirth. 2014;14:348. Epub 2014/10/07. pmid:25284336
- 22. Raheel H, Karim MS, Saleem S, Bharwani S. Knowledge, attitudes and practices of contraception among Afghan refugee women in Pakistan: a cross-sectional study. PLoS One. 2012;7(11):e48760. Epub 2012/11/08. pmid:23133658
- 23. Blanchet K, Ramesh A, Frison S, Warren E, Hossain M, Smith J, et al. Evidence on public health interventions in humanitarian crises. Lancet. 2017;390(10109):2287–96. Epub 2017/06/13. pmid:28602563
- 24. Botfield JR, Newman CE, Zwi AB. Young people from culturally diverse backgrounds and their use of services for sexual and reproductive health needs: a structured scoping review. Sex Health. 2016;13(1):1–9. Epub 2015/09/28. pmid:26409644
- 25. Mason-Jones AJ, Nicholson P. Structural violence and marginalisation. The sexual and reproductive health experiences of separated young people on the move. A rapid review with relevance to the European humanitarian crisis. Public Health. 2018;158:156–62. pmid:29653866
- 26.
United Nations High Commissioner for Refugees, UNHCR. Policy on Alternatives to Camps [Internet]. 2019 [cited 2019 Sep 4]. https://www.unhcr.org/pages/54d9c7686.html.
- 27.
United Nations High Commissioner for Refugees, UNHCR. Resettlement [Internet]. 2020. [cited 2020 June 18]. https://www.unhcr.org/en-au/resettlement.html.
- 28. Kaufman MR, Cornish F, Zimmerman RS, Johnson BT. Health behavior change models for HIV prevention and AIDS care: practical recommendations for a multi-level approach. Journal of acquired immune deficiency syndromes (1999). 2014;66 Suppl 3(Suppl 3):S250–S8.
- 29.
Bronfenbrenner U. The ecology of human development. Cambridge, MA: Harvard University Press; 1979.
- 30. Davis K, Drey N, Gould D. What are scoping studies? A review of the nursing literature. International journal of nursing studies. 2009;46(10):1386–400. Epub 2009/03/31. pmid:19328488
- 31. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. International journal of evidence-based healthcare. 2015;13(3):141–6. Epub 2015/07/03. pmid:26134548
- 32. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19–32.
- 33. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implementation science: IS. 2010;5:69. Epub 2010/09/22.
- 34.
The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2015 Edition [Internet]. The Joanna Briggs Institute. 2015 [cited 2019 Oct 3]. https://joannabriggs.org/assets/docs/sumari/Reviewers-Manual_Methodology-for-JBI-Scoping-Reviews_2015_v2.pdf.
- 35.
The United Nations. World Youth Report—Youth and the 2030 Agenda for Sustainable Development [Internet]. The United Nations. 2018 [cited 2019 Sep 29]. https://www.un.org/development/desa/youth/world-youth-report.html.
- 36.
International Organization for Migration, IOM. Key Migration Terms [Internet]. 2019. https://www.iom.int/key-migration-terms.
- 37. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210-. pmid:27919275
- 38. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology. 2008;8:45. Epub 2008/07/12. pmid:18616818
- 39. Kondracki NL, Wellman NS, Amundson DR. Content analysis: review of methods and their applications in nutrition education. Journal of nutrition education and behavior. 2002;34(4):224–30. Epub 2002/09/10. pmid:12217266
- 40. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today. 2004;24(2):105–12. Epub 2004/02/11. pmid:14769454
- 41.
Hannes K. Chapter 4: Critical appraisal of qualitative research 2011 [cited 2019 Oct 1]. Version 1:[http://methods.cochrane.org/qi/sites/methods.cochrane.org.qi/files/uploads/Chapter_Guidancecritical_appraisal.doc.
- 42. Armijo-Olivo S, Stiles CR, Hagen NA, Biondo PD, Cummings GG. Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. J Eval Clin Pract. 2012;18(1):12–8. Epub 2010/08/12. pmid:20698919
- 43. Benner M, Townsend J, Kaoloi W, Htwe K, Naranichakul N, Hunnangkul S, et al. Reproductive health and quality of life of young Burmese refugees in Thailand. Conflict and Health. 2010;4(5).
- 44.
Connelly M. Baseline Study: Documenting Knowledge, Attitudes and Practices of Iraqi Refugees and the Status of Family Planning Services in UNHCR’s Operations in Amman, Jordan 2011. https://www.womensrefugeecommission.org/resources/reproductive-health/755-family-planning-baseline-study-jordan/file.
- 45.
Cornier N, Krause S, Tanabe M. Refocusing Family Planning in Refugee Settings: Findings and Recommendations from a Multi-Country Baseline Study November 2011 2013. https://www.unhcr.org/en-au/protection/health/4ee6142a9/refocusing-family-planning-refugee-settings-findings-recommendations-multi.html.
- 46. Dean J, Mitchell M, Stewart D, Debattista J. Intergenerational variation in sexual health attitudes and beliefs among Sudanese refugee communities in Australia. Cult Health Sex. 2017;19(1):17–31. Epub 2016/06/09. pmid:27268405
- 47. DeJong J, Sbeity F, Schlecht J, Harfouche M, Yamout R, F. FM, et al. Young lives disrupted: gender and well-being among adolescent Syrian refugees in Lebanon. Conflict and Health. 2017;11(23).
- 48. Kingori C, Esquivel CL, Hassan Q, Elmi A, Mukasa B, Reece M. Recommendations for Developing Contextually Relevant HIV/AIDS Prevention Strategies Targeting African-Born Immigrants and Refugees in the United States. AIDS patient care and STDs. 2016;30(10):476–83. Epub 2016/10/18. pmid:27749109
- 49. Kågesten AE, Zimmerman L, Robinson C, Lee C, Bawoke T, Osman S, et al. Transitions into puberty and access to sexual and reproductive health information in two humanitarian settings: a cross-sectional survey of very young adolescents from Somalia and Myanmar. Conflict and Health. 2017;11(24).
- 50.
Lane C. Adolescent Refugees and Migrants: A Reproductive Health Emergency 2008 [cited 2019 Sep 17]. https://www.pathfinder.org/publications/adolescent-refugees-migrants-reproductive-health-emergency/.
- 51.
Lowicki-Zucca J. Scattered Dreams, Broken Promises: An Assessment of the Links between Girls’ Empowerment and Gender-based Violence in the Kyaka II Refugee Settlement, Uganda [Internet]. 2013 [cited 2019 Sep 17]. https://www.womensrefugeecommission.org/resources/document/921-scattered-dreams-broken-promises.
- 52. Mantovani N, Thomas H. Choosing motherhood: the complexities of pregnancy decision-making among young black women ’looked after’ by the State. Midwifery. 2014;30(3):e72–8. Epub 2013/11/23. pmid:24262702
- 53. McMichael C, Gifford S. “It is Good to Know Now…Before it’s Too Late”: Promoting Sexual Health Literacy Amongst Resettled Young People With Refugee Backgrounds. Sexuality & Culture. 2009;13:218–36.
- 54. McMichael C, Gifford S. Narratives of sexual health risk and protection amongst young people from refugee backgrounds in Melbourne, Australia. Cult Health Sex. 2010;12(3):263–77. Epub 2009/11/12. pmid:19904650.
- 55. Ngum Chi Watts MC, Liamputtong P, Carolan M. Contraception knowledge and attitudes: truths and myths among African Australian teenage mothers in Greater Melbourne, Australia. J Clin Nurs. 2014;23(15–16):2131–41. Epub 2013/09/14. pmid:24028778
- 56.
Watts M, McMichael C, Liamputtong P. Factors Influencing Contraception Awareness and Use: The Experiences of Young African Australian mothers [Internet]. 2015 [cited 2019 Sep 29]. https://academic.oup.com/jrs/article-abstract/28/3/368/1909088/.
- 57. Ngum Chi Watts MC, Liamputtong P, McMichael C. Early motherhood: a qualitative study exploring the experiences of African Australian teenage mothers in greater Melbourne, Australia. BMC Public Health. 2015;15:873. Epub 2015/09/12. pmid:26358465
- 58. Okanlawon K, Reeves M, Agbaje OF. Contraceptive use: knowledge, perceptions and attitudes of refugee youths in Oru Refugee Camp, Nigeria. Afr J Reprod Health. 2010;14(4 Spec no.):16–25. Epub 2011/08/05. pmid:21812194
- 59. Ortiz-Echevarria L, Greeley M, Bawoke T, Zimmerman L, Robinson C, Schlecht J. Understanding the unique experiences, perspectives and sexual and reproductive health needs of very young adolescents: Somali refugees in Ethiopia. Conflict and Health. 2017;11(26).
- 60.
Paik K. The Path to Hope: Congolese Refugee Adolescent Girls in Nyarugusu Refugee Camp, Tanzania New York: Women’s Refugee Commission; 2011. https://www.womensrefugeecommission.org/resources/document/868-the-path-to-hope-congolese-refugee-adoles-cent-girls-in-nyarugusu-refugee-camp-tanzania.
- 61.
Plan International. Tanzania: Girls Clubs Essential to Equity in Education. Washington: 2018.
- 62.
Schulte J, Rizvi Z. In Search of Safety and Solutions: Somali Refugee Adolescent Girls at Sheder and Aw Barre Camps, Ethiopia: Women’s Refugee Commission; 2012. https://www.womensrefugeecommission.org/populations/adolescent-girls/research-and-resources/834-in-search-of-safety-and-solutions-somali-refugee-adolescent-girls-at-sheder-and-aw-barre-camps.
- 63.
Tanabe M. "It doesn’t matter if you are disabled. You are talented"—The intersection of sexual and reproductive health and disability for Bhutanese refugees in Damak, Nepal [Internet]. 2014 [cited 2019 Oct 1]. https://www.refworld.org/docid/57ff52d84.html.
- 64.
Tanabe M. "The woman can decide for herself"—The Intersection of Sexual and Reproductive Health and Disability for Refugees in Kakuma Refugee Camp, Kenya [Internet]. 2016 [cited 2019 Sep 29]. https://www.refworld.org/docid/57ff70514.html
- 65.
Tanabe M, Schlecht J, Manohar S. Adolescent Sexual and Reproductive Health Programs in Humanitarian Settings: An In-Depth Look at Family Planning Services [Internet]. 2012 [cited 2019 Sep 29]. https://www.womensrefugeecommission.org/resources/document/901-adolescent-sexual-and-reproductive-health-programs-in-humanitarian-settings-an-in-depth-look-at-family-planning-services%20.
- 66.
Tanabe M, Nagujja Y. “We have a right to love"—The Intersection of Sexual and Reproductive Health and Disability for Urban Refugees in Kampala, Uganda [Internet]. Women’s Refugee Commission. 2014 [cited 2019 Oct 1]. https://www.refworld.org/docid/57ff6fa54.html
- 67. Tanabe M, Nagujjah Y, Rimal N, Bukania F, Krause S. Intersecting Sexual and Reproductive Health and Disability in Humanitarian Settings: Risks, Needs, and Capacities of Refugees with Disabilities in Kenya, Nepal, and Uganda. Sexuality and Disability. 2015;33(4):411–27. pmid:26594076
- 68. Tanabe M, Myers A, Bhandari P, Cornier N, Doraiswamy S, Krause S. Family planning in refugee settings: findings and actions from a multi-country study. Conflict and Health. 2017;11:12. pmid:28680460
- 69.
Tanner S, O’Connor M. A Safe Place to Shine: Creating Opportunities and Raising Voices of Adolescent Girls in Humanitarian Settings 2017. https://reliefweb.int/report/democratic-republic-congo/safe-place-shine-creating-opportunities-and-raising-voices.
- 70.
Turkmen Sanduvac ZM. Menstrual Hygiene Management (MHM) for Education in Emergencies (EiE): A Study for Plan International Tanzania 2017. https://reliefweb.int/report/united-republic-tanzania/menstrual-hygiene-management-mhm-education-emergencies-eie-study.
- 71.
United Nations High Commissioner for Refugees, UNHCR. Through the Eyes of a Child: Refugee Children Speak about Violence—A Report on Participatory Assessments Carried out with Refugee and Returnee Children in Southern Africa 2008 [updated Sep 7; cited 2019 Oct 1]. 2019:[https://reliefweb.int/report/world/through-eyes-child-refugee-children-speak-about-violence-report-participatory.
- 72.
Women’s Refugee Commission—The Consortium. Very Young Adolescents in Humanitarian Settings: Examining the Sexual and Reproductive Health Needs and Risks of Girls and Boys Aged 10–14 in Ethiopia, Lebanon and Thailand: Women’s Refugee Commission 2014 [updated 2019 Sep 7; cited 2019 Oct 1]. https://www.womensrefugeecommission.org/girls/resources/1094-very-young-adolescents-in-humanitarian-settings-examining-the-sexual-and-reproductive-health-needs-and-risks.
- 73. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. Jama. 1997;278(12):1029–34. Epub 1997/11/05. pmid:9307357
- 74. Berlan ED, Bravender T. Confidentiality, consent, and caring for the adolescent patient. Current opinion in pediatrics. 2009;21(4):450–6. Epub 2009/05/29. pmid:19474734
- 75. Lehrer JA, Pantell R, Tebb K, Shafer MA. Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern. J Adolesc Health. 2007;40(3):218–26. Epub 2007/02/27. pmid:17321421
- 76. Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet (London, England). 2016;387(10036):2423–78. Epub 2016/05/09.
- 77. Brown A, Rice SM, Rickwood DJ, Parker AG. Systematic review of barriers and facilitators to accessing and engaging with mental health care among at-risk young people. Asia Pac Psychiatry. 2016;8(1):3–22. Epub 2015/08/05. pmid:26238088
- 78. Hartmann M, Khosla R, Krishnan S, George A, Gruskin S, Amin A. How Are Gender Equality and Human Rights Interventions Included in Sexual and Reproductive Health Programmes and Policies: A Systematic Review of Existing Research Foci and Gaps. PLoS One. 2016;11(12):e0167542. Epub 2016/12/22. pmid:28002440
- 79. Orza L, Crone T, Mellin J, Westerhof N, Stackpool-Moore L, Restoy E, et al. Searching for the Second R in Sexual and Reproductive Health and … Rights. J Adolesc Health. 2017;60(2s2):S10–s4. Epub 2017/01/23. pmid:28109334