Understanding barriers to young people’s utilisation of sexual and reproductive health services in Asia-Pacific countries: a qualitative systematic review and thematic synthesis

Abstract

Introduction

Based on the United Nations’ sustainable development goals, universal access to sexual and reproductive health (SRH) services should be attained by 2030. Yet, large inequalities in adolescent SRH knowledge and service use still exist both within and between countries. The goal of this study was to identify and synthesise published qualitative research on factors affecting young people’s utilisation of SRH services in Asia-Pacific countries.

Methods

We systematically searched five electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science) for qualitative studies reporting the experiences, attitudes and views of young people (aged 10–24 years) regarding the utilisation of SRH services in Asia-Pacific countries. We assessed the quality of identified studies using the Critical Appraisal Skills Programme qualitative checklist and employed a thematic synthesis approach for the data analysis.

Results

We included 31 articles that reported the experiences of over 1800 young people from 15 different countries. Thematic synthesis identified six descriptive themes that captured factors influencing SRH service utilisation: (1) navigating puberty; (2) knowledge and beliefs about SRH; (3) embarrassment and confidentiality concerns; (4) low decision-making autonomy; (5) traditional practices and religious beliefs; and (6) social and gender norms. Based on these, we developed an overarching analytical theme, ‘trapped in a legacy of shame’, which highlights the role of shame as a key emotion associated with young people’s utilisation of SRH services.

Conclusion

Our findings point towards the necessity of integrating shame-sensitive approaches and a social norms perspective in interventions aiming to improve young people’s SRH outcomes in Asia-Pacific countries.

PROSPERO registration number

CRD42023389653.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Despite a growing policy focus on the implementation of youth-friendly sexual and reproductive health (SRH) services in the Asia-Pacific region, utilisation rates remain low.

WHAT THIS STUDY ADDS

• Bringing together the findings of over 30 publications reporting the experiences and views of young people about SRH services in Asia-Pacific countries, this qualitative evidence synthesis sheds light on the key barriers to access and explicitly articulates shame as a driving force for young people’s SRH decision-making.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• SRH decision-making never occurs in an emotional vacuum and the mechanisms and outcomes of shame need to be further explored, especially among young, marginalised populations, such as migrants and refugees, sex workers, people who inject drugs and lesbian, gay, bisexual, transgender or queer/questioning people.

• Integrating shame-sensitive approaches and a social norms perspective in interventions aiming to improve young people’s SRH outcomes in Asia-Pacific countries is likely to increase their effectiveness.

Introduction

The period spanning adolescence and young adulthood, covering the ages between 10 and 24 years, has traditionally been regarded as a time of peak physical health. In most countries, this is the period of the life span with the lowest mortality, following the peaks of infant and child mortality, while preceding the development of chronic disease later in life.¹ This view of adolescent health has substantially shaped research and care provision for young people, with their health needs historically receiving considerably less attention and investment compared with those of other age groups.1,3 This is particularly true for their sexual and reproductive health (SRH) needs, which have for long been disregarded, despite overwhelming evidence that unmet SRH needs during adolescence have detrimental effects, not only on the health and well-being of young people (eg, risks associated with early pregnancy, unsafe abortions, sexually transmitted infections [STIs] and HIV), but also on their families and society at large (eg, impacting on education, economic participation and poverty).4,8

Important progress has been made since the 1994 International Conference on Population and Development placed adolescent SRH on the global agenda.⁹ Highlights have included, among others, the WHO’s 2001 Global Consultation on Adolescent-Friendly Health Services,¹⁰ advocating for the implementation of services that are sensitive to adolescents’ unique stage of biological, cognitive and psychosocial transition into adulthood, as well as subsequent guidelines and national quality standards for ensuring that such services are ‘accessible, acceptable, equitable, appropriate and effective’.^{11 12} Based on the United Nations’ (UN) sustainable development goals (target 3.7), universal access to SRH services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes, should be attained by 2030.¹³ Yet, large inequalities in adolescent SRH knowledge and service use still exist both within and between countries.14,17

Asia and the Pacific are home to 60% of the world’s young population, with approximately 1 billion people aged 10–24 years living in 32 low- and middle-income countries (LMICs).¹⁸ One in seven girls in the region has given birth by the age of 18, usually in the context of high unmet need for contraception and child marriage.¹⁹ In 2020, the adolescent birth rate in Bangladesh was as high as 83.0 per 1000 girls aged 15–19 years, followed by 65.4 in Lao PDR and 65.1 in Nepal.²⁰ Approximately one in eight adolescent pregnancies in the region are unintended, whereas it is estimated that around 3.6 million unsafe abortions occur annually.¹⁸ While the prevalence of HIV is generally low, Asia and the Pacific have the second highest number of people living with HIV, with more than one-quarter of all new HIV diagnoses occurring in adolescents and young adults.²¹ Furthermore, new HIV infections disproportionately affect young key populations (ie, men who have sex with men, transgender people, people who inject drugs and female sex workers), who have the poorest access to essential SRH knowledge and services.¹⁹

Young people’s perceived barriers to accessing SRH services in Asia-Pacific countries have been well documented in the qualitative literature. Attempts, however, to synthesise this growing body of work, so that it becomes more easily accessible and usable for healthcare policy and practice, are non-existent. We therefore sought to systematically search and synthesise published qualitative research in this area in order to provide a comprehensive picture of key barriers to access, as well as a more nuanced understanding of where future initiatives targeting Asia and the Pacific should be focused.

Methods

We conducted a systematic review and thematic synthesis of published qualitative literature on young people’s decision-making regarding utilisation of SRH services in Asia-Pacific countries. We used the WHO’s definition of ‘young people’,²² which covers both ‘adolescents’ (ie, individuals in the 10–19 age group) and ‘youth’ (ie, those in the 15–24 age group), and the UN’s definition of ‘Asia-Pacific countries’.²³ A protocol for the review was developed in advance and was registered with PROSPERO (CRD42023389653). The ENhancing Transparency in REporting the synthesis of Qualitative research checklist²⁴ was used to guide the reporting of this review (online supplemental table S1).

Search strategy

We used the PICo framework²⁵ (Population=Young People; phenomenon of Interest=Utilisation of SRH services; and Context=Asia-Pacific countries) to develop a comprehensive search strategy and determine inclusion/exclusion criteria. Five electronic databases were searched from inception until 24 June 2022: MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science (Social Sciences Citation Index, Science Citation Index Expanded, Conference Proceedings Citation Index-Science and Conference Proceedings Citation Index-Social Science & Humanities). An example of the search strategy used for MEDLINE is shown in online supplemental table S2. To identify additional relevant studies, we also performed a search on Google Scholar and hand-searched the reference lists of all included studies.

Selection criteria

We included original research articles that (1) reported the experiences, attitudes and views of young people (aged 10–24 years) regarding the utilisation of SRH services; (2) were conducted in Asia-Pacific countries; (3) employed both qualitative data collection (eg, in-depth interviews, focus groups) and qualitative data analysis methods (eg, thematic analysis, interpretative phenomenological analysis) and (4) were published in English. We excluded mixed-methods studies that did not report the qualitative results in sufficient detail. We also excluded studies that involved various age or population groups (eg, young people and older adults, or young people and healthcare professionals) and did not discuss separately or adequately the experiences and views of young people. When a single study was reported across multiple papers, we only included one, unless additional papers offered new insights.

Data screening and quality assessment

References identified through the electronic search were imported into EndNote and duplicates were removed. Two reviewers (WR and BG) independently screened all titles and abstracts against predetermined inclusion criteria and then reviewed the full texts of potentially eligible studies. Any discrepancies in screening decisions were resolved either through discussion between the two reviewers or through consultation with a third reviewer (EG). Key study information, such as sample and country, was extracted into an Excel spreadsheet. The 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research²⁶ was used to assess the reporting quality of included studies. As with screening, quality assessment was carried out by two independent reviewers (WR and BG), with a third (EG) available to resolve disagreements. For the first nine CASP items (eg, ‘Have ethical issues been taken into consideration?’), we recorded our answers with a ‘yes’ or ‘no’. For the last (ie, ‘How valuable is the research?’), we sought to make an overall judgement about the value of each study and its potential contribution to the synthesis, recording our answers with a ’high’, ‘medium’ or ‘low’, and eventually excluding from the synthesis the ones rated as ‘low’.

Data analysis

We used thematic synthesis, an approach similar to thematic analysis used in primary qualitative research. Thematic synthesis was preferred as it allows for considerable flexibility with regard to the type of data that can be included in the synthesis, namely both ‘thick’ (ie, more conceptually rich) and ‘thin’ (ie, more descriptive) data can be incorporated.²⁷ In line with the three-stage process proposed by Thomas and Harden,²⁸ the first author (WR) began by performing line-by-line coding of the findings of all included studies and then organising these codes into related areas in order to develop initial, descriptive themes. These themes, which were still very close to the original findings, were presented and discussed with the last author (EG) in an effort to go beyond the content of the primary studies and start generating novel understandings. An overarching analytical theme was subsequently developed through an iterative process, which involved moving back and forth between original studies, descriptive themes and emerging concepts.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct or reporting of this review.

Results

Literature search and critical appraisal

Our search yielded a total of 2559 unique citations: 2530 were identified from the five electronic databases and 29 from other sources (figure 1). Of these, 159 full-text articles were assessed for eligibility, with 35 meeting the inclusion criteria and proceeding to critical appraisal. Figure 2 presents the percentage of studies meeting each of the nine ‘yes/no’ CASP items. All criteria were met by at least 91% of the studies, with the exception of item 6 referring to the relationship between researcher and participants (eg, critical examination of the researcher’s own role, potential bias and influence during the research process), which was inadequately discussed in 15 (43%) of the studies. In terms of their overall value and potential contribution to the synthesis, a total of four studies were rated as ‘low’ and were excluded from the synthesis. Among them, one did not discuss ethical considerations, one did not include a clear presentation of themes identified from the data analysis and two did not present participant quotes to support authors’ claims.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of study selection.

Figure 2. Percentage of studies meeting the Critical Appraisal Skills Programme criteria (n=35).

Characteristics of included studies

The characteristics of the 31 papers29,59 that were included in the synthesis are shown in online supplemental table S3. The papers corresponded to 29 studies (24 qualitative and 5 mixed-methods), published from 2007 onwards and reporting the experiences of more than 1800 young people living in 15 different Asia-Pacific countries. In-depth interviews, focus groups or a combination of both were the main methods of data collection, while thematic analysis was the most frequently used data analysis technique.

Thematic synthesis

Thematic synthesis identified six descriptive themes that captured main factors influencing SRH service utilisation: (1) navigating puberty; (2) knowledge and beliefs about SRH; (3) embarrassment and confidentiality concerns; (4) low decision-making autonomy; (5) traditional practices and religious beliefs; and (6) social and gender norms. Based on these, we developed an overarching analytical theme, ‘trapped in a legacy of shame’, which highlights the role of shame as a key emotion associated with young people’s utilisation of SRH services in Asia-Pacific countries (figure 3).

Figure 3. Descriptive and analytical themes identified in the synthesis.

Descriptive themes

Navigating puberty

Navigating the physical changes of puberty, such as breast development and the onset of menstruation in girls or growing facial hair in boys, often caused stress and feelings of confusion: “I was all mixed up at first. My height suddenly grew and I developed beard and moustache. It was hard to digest. I was only a happy kid without facial hairs. Well, changes happen. I felt I was grown up now, and that was it”.³² Adolescents were trying to make sense of what was going on in their bodies and wanted to know how to deal with these changes. As curiosity about sex increased, so did their concerns and insecurities about their own bodies and future sexual performance. Friends were typically the first port of call, although the openness with which they discussed their concerns was variable: "You can forward the problem to your friends pretending that it has happened to one of your friends. Then they discuss it and you can get a clue of what to do”.²⁹ Incidents of peer bullying and marginalisation due to puberty changes were also described: “I got bullied by my friends since the day I got my first menstruation (pause). They bullied me because the blood in my skirt uniform (pause) was shameful (pause) that is the reason why I left school (pause), but I then feel free now (pause) I have a boyfriend who supported me…he said he would marry me next year”.³⁰

Knowledge and beliefs about SRH

In most countries, SRH education was not part of the school curriculum, and sexuality was seen as a taboo topic to discuss with (unmarried) young people: “Our teacher was always reluctant to talk about issues of puberty and reproductive system. She feared kids would report her to the headmaster and families”.³² Lack of access to correct and complete information led to misconceptions about SRH and inadequate knowledge of available services, which were often thought of as being only for married people.⁴¹ Many young girls reported that they got to know about contraceptive methods only after they got pregnant or after they had their first child. Beliefs that contraception use would be harmful or might cause infertility were also widespread: “My husband told me to delay to take baby but I thought it (pills) will give me an inflammation in my belly button if I have it! People also said that if you eat [take] pills you will not have baby in the future”.⁴⁸ In Bangladesh, quacks selling medicines and herbs in the streets with the promise of increasing sexual power and penis size, were a common source of sexuality-related information for young boys, who expressed fears that masturbation and wet dreams would have a negative impact on their school performance, physical strength, and sexual and reproductive power.⁵⁷

Embarrassment and confidentiality concerns

Young people reported feeling embarrassed to talk about SRH with significant others, such as parents or teachers, and were afraid that they would be seen as promiscuous if they used SRH services: “I am aware that having a conversation with others may give opportunities to solve problems, even things related to sexuality (pause). However, I feel worried if people know about that, they may think that I am naughty …”.³⁰ When talking about their pregnancy, young women from Turkey referred to the concept of ‘utanma’, which covers both ‘embarrassment’ and ‘shame’, and described how they avoided visiting healthcare services in the hope that their pregnancy—a direct manifestation of having engaged in sexual intercourse—would go unnoticed: “Vallahi (upon my word) I am ashamed, my brother is sick but I cannot even go to (see) him because of my embarrassment. It is disgraceful in here, we feel embarrassed/ashamed … I did not talk with anyone in my life regarding my pregnancy, I mean with my family, not with my spouse’s family, not with my (birth) family. There are nurses, there are doctors, but still I do not go (to a health centre)”.³¹ In addition, ‘utanma’ was used to express their feelings about being seen by a male healthcare professional, and the same sentiment was echoed by adolescents in many countries (both boys and girls), who reported that they would feel embarrassed to talk to or be examined by a different sex practitioner. Privacy and confidentiality concerns were also common, with young people describing how living in villages or small towns could facilitate gossip and cause embarrassment to themselves and their families: “If I visit the health facility and if this information reaches from the health care provider to my villagers, then it is a matter of shyness in public. My parents will get embarrassed, and in total, if all society knows this information, they will make gossip”.⁴⁵

Low decision-making autonomy

Young people felt that the decision to use SRH services was often beyond their control: “Young people are not always free to access SRH services because of community rules or parents stop us”.³⁸ The perception that they were ‘too young’ to be sexually active and make decisions about SRH issues had an impact on their views of what might be ‘legitimate’ reasons for using SRH services, with many reporting that they would visit such services only for ‘serious’, that is, life-threatening, conditions. In many societies, being a young woman seemed to automatically grant decision-making authority to more ‘knowledgeable’ others, namely parents in the case of unmarried girls, or husbands and in-laws in the case of married girls: “My husband didn't agree to use the family planning devices. My mother and father-in-law also would not agree if we were not having a baby after marriage. They insisted on me having a baby”.⁴³ Not being financially independent further limited young people’s decision-making autonomy, especially in cases where out-of-pocket payments were required to access treatment: “I took a gay friend to a clinic, and he was diagnosed with HPV and wanted to get treatment but could not afford to pay [for] it (~$45 US). And he did not dare to ask his parents for that amount of money. They would question and think that oh, you must be gay to get that disease”.⁴⁶

Traditional practices and religious beliefs

Traditional practices—a society’s inherited and established ways of acting—played a crucial role in young people’s decision-making regarding SRH service utilisation. In Bangladesh, for example, young girls’ decisions to deliver their baby at home, instead of a hospital, seemed to be the result of a combination of factors, including preserving the family tradition of giving birth with the help of relatives and older women who have experience in childbirth.⁴⁹ Traditional practices were often intertwined with spiritual and religious beliefs, which significantly shaped SRH thinking and acting. Beliefs about the impurity of menstrual blood, for instance, led many girls to hold the view that during menstruation they should not touch anyone or go outside, otherwise they would get affected by a ‘bad wind’ (ie, evil spirit) and suffer from excessive bleeding.⁵⁷ As such, traditional and spiritual healers were frequently regarded as the main providers of SRH services, with young people reporting that they would go to them for a range of problems, including STIs, abortion and pregnancy-related problems: “Because my first baby died so everyone said there was an evil spirit on me. Then I got my house purified (ghor bondo kora). Me and the baby (newborn) got tabij (holly pendant) on our neck. That’s all”.⁴⁹

Social and gender norms

Social and gender norms around sexuality exerted an important influence on both the provision and utilisation of SRH services. In Vanuatu, for instance, ‘kastom’, that is, the traditional culture, was seen by adolescents as a key barrier to accessing SRH services. Often described in terms of ‘community rules’ upheld by community leaders (chiefs), ‘kastom’ contributed to stigma around adolescent sexual behaviour, inhibited open discussion of sexual matters and impeded the provision of SRH services, such as condom distribution: “Young people ask for condoms, but health workers don’t want to give them”.³⁸ Similarly, in Nepal, premarital sexual activity, especially among girls, was described as ‘kharab bani’ (ie, bad behaviour), with young people reporting that healthcare professionals were reluctant to provide SRH services to unmarried adolescents in the fear that this would encourage promiscuity: “Health care professionals would say contraceptive is of no use to unmarried adolescents, and they should not use it before marriage”.⁴⁵ Negative experiences from previous interactions with SRH services, focusing mostly on judgemental staff attitudes, were commonly reported, with young unmarried women and those belonging to sexual minorities facing the biggest challenges: “One time I went to see the gynaecologist in the fee-for-service ward [of this hospital]. At the registration desk, I told the nurse-midwife that I had irregular periods … As soon as I mentioned that I was single she suddenly became rude to me … and … wrote in the medical records, without saying another word to me, that if [it turns out that] I am pregnant, then I will have an abortion. But I said no such a thing! I didn’t mention anything about pregnancy or abortion, just that my period has been irregular. She [wrongfully] assumed that because I was a single woman … I must be coming in for an abortion … I’ve been reluctant to go back ever since”.³⁷

Analytical theme

Trapped in a legacy of shame

Our overarching analytical theme highlights the role of shame as a key emotion associated with young people’s utilisation of SRH services in Asia-Pacific countries. Across the studies, narratives of shame were pervasive, with adolescent sexuality being viewed as a taboo topic to discuss and even normal changes of puberty, such as menstruation or breast development, turning into sites of shame and marginalisation. Social and gender norms about who is a legitimate user of SRH services, namely married and heterosexual adults, were perpetuated by family members and reinforced by community leaders, leading young people to believe that SRH services are not for them and that they would be transgressing moral values if they used them. As such, SRH service utilisation was typically regarded as a last resort and was accompanied by feelings of shame, which were often intensified due to (actual or anticipated) judgemental staff attitudes or unmet privacy and confidentiality needs.

Discussion

Despite a growing policy focus on the implementation of youth-friendly SRH services in Asia-Pacific countries, utilisation rates remain low.^{45 60 61} This systematic review and thematic synthesis of qualitative evidence sought to provide a comprehensive picture of key barriers to access, as perceived by young people themselves, and offer a more nuanced understanding of where future initiatives should be focused. Drawing on 31 articles reporting the experiences of more than 1800 young people from 15 different countries, we identified six descriptive themes (navigating puberty; knowledge and beliefs about SRH; embarrassment and confidentiality concerns; low decision-making autonomy; traditional practices and religious beliefs; and social and gender norms) and an overarching analytical theme (trapped in a legacy of shame), which highlights the role of shame as a key emotion associated with young people’s utilisation of SRH services.

Although international literature on young people’s views and experiences of SRH services is filled with emotional accounts—for instance, words like ‘embarrassment’, ‘shame’ or ‘fear of being judged’ feature extensively in publications coming from high-income countries and LMICs alike1762,64—it is striking how under-acknowledged and under-researched the role of emotions remains. In a way, it could be argued that, when it comes to young people’s SRH, emotions are still the ‘elephant in the room’⁶⁵: something so big and important that everyone knows about, but no one wishes to discuss. And this is exactly where the significance of this evidence synthesis lies. By bringing together the findings of multiple and diverse qualitative studies, we were able to reach a better understanding of the nature and mechanisms of shame in Asia-Pacific countries, and explicitly articulate it as a driving force for young people’s SRH decision-making.

Shame, according to Probyn,⁶⁶ is probably the most intimate of feelings, but is brought into being by close proximity to others, therefore it ‘always plays on that doubledness of the public and the private’. Unlike more ‘primary’ or ‘basic’ emotions (eg, joy, anger, or sadness), shame—like its ‘lighter’ variant, embarrassment—is typically viewed as a self-conscious evaluative emotion since it involves the ability to compare oneself (or one’s behaviour) with an internalised social norm and respond to the outcome of this evaluation.⁶⁷ A disapproving audience (real or imaginary) is therefore a key requirement for shame.⁶⁸ In our review, we found that young people’s SRH beliefs and practices were rooted in social and gender norms, perpetuated by their families and reinforced by community leaders. Not fitting the acceptable picture of a legitimate SRH service user (ie, being too young, being unmarried or being homosexual) gave rise to feelings of shame, which were often intensified through interactions with healthcare staff, acting (or perceived to be acting) as a ‘disapproving audience’. As such, many young people regarded SRH service utilisation as a last resort option when they faced a serious or life-threatening problem and when other, more socially accepted help-seeking efforts (eg, help sought from traditional and spiritual healers) had failed.

Our findings resonate with prior qualitative work on young women’s experiences of accessing emergency contraception in the UK,⁶⁹ while also corroborating the universal, but at the same time contextual, nature of shame. Specifically, Fallon⁶⁹ showed that being too young, having sex too soon within a relationship or needing emergency contraception too often were all precursors to feelings of shame, which led many young women to avoid seeking help. She also cautioned that more attention needs to be paid to the complex relationships that young people have with adults around them, as significant others, including parents, teachers and healthcare professionals, may unintentionally act as ‘shamers’. More recently, Dolezal and Lyons⁷⁰ argued that the impact of shame on health, illness and health-related behaviours is ‘sufficiently powerful for it to be considered an affective determinant of health’ and called for more research in the area, including identifying disease-specific, cultural, institutional and sociopolitical factors that mediate reactions and outcomes. We echo this call and encourage future SRH research from Asia and the Pacific to focus more on how shame operates, especially for marginalised populations, such as young migrants and refugees, sex workers, people who inject drugs and lesbian, gay, bisexual, transgender or queer/questioning people, whose experiences were under-represented in this review. The lack of quality sexuality education in these countries and the extent to which this contributes to maintaining a ‘legacy of shame’ also requires further investigation. Indeed, although most Asia-Pacific countries have now enacted some form of legislation or policy related to SRH and/or sexuality education for young people, implementation of age-appropriate comprehensive sexuality education remains minimal.⁷¹

We used rigorous and transparent methods to bring the findings of individual qualitative studies, conducted in a range of contexts, closer to decision-making. Yet, our work relied solely on literature published in English, which, we acknowledge, might give rise to two issues. The first, and most obvious one, is that we might have missed important multilingual contributions. Although only two potentially relevant papers were excluded on the grounds of language, it is worth noting that our search did not go beyond mainstream international databases, which are largely English language based. The second has to do with a ‘lost-in-translation’ effect arising from the fact that the language of publication is not the same as the language in which data collection was carried out. This translation process, although bringing the voices of less explored non-English-speaking populations into the global body of knowledge,⁷² is not without challenges. Language differences can affect the interpretation of meanings, which is particularly crucial in qualitative research, and can thereby jeopardise the trustworthiness of the findings.⁷³ In an apparent effort to preserve participants’ meanings, several of the studies included in this review had provided the original (non-English) terms for important concepts described in the text. We opted for including some of these terms here (eg, the Turkish word ‘utanma’ covering both ‘embarrassment’ and ‘shame’) as a way of safeguarding the depth and richness of individual works.

Conclusion

Our findings add to an extensive body of work suggesting that increasing young people’s knowledge of SRH or access to services will not by itself lead to improved SRH outcomes. Rather, shifts in social norms around adolescent sexuality and SRH service utilisation are required to increase young people’s agency over their health and healthcare decisions.74,77 Most importantly, this qualitative evidence synthesis brings to the forefront the role of shame as a key emotion associated with young people’s utilisation of SRH services in Asia-Pacific countries. SRH decision-making never occurs in an emotional vacuum, even less so in adolescence and young adulthood, and the mechanisms and outcomes of shame need to be further explored. Integrating shame-sensitive approaches and a social norms perspective in interventions aiming to improve young people’s SRH outcomes in Asia-Pacific countries is likely to increase their effectiveness. Stronger political commitment on the implementation of comprehensive sexuality education that goes beyond simply providing information on reproduction, risks and diseases, to address the broader sociocultural and gender influences on SRH, is also essential.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.