Accessibility and Quality of Sexual and Reproductive Health services for Adolescents in The Gambia

Abstract

Background: Adolescents in The Gambia face significant SRH challenges, such as HIV/AIDS,
teenage pregnancy, and unmet contraceptive needs. Despite the World Health
Organisation’s recommendation on adolescent-friendly health services (AFHS) to address
these challenges, implementation in The Gambia remains inadequate, and evidence on how
services meet adolescents’ needs has not been evaluated. This thesis aimed to examine the
SRH needs, access, and quality of SRH services, and to inform context-specific strategies for
improving service quality for the future implementation of AFHS for adolescents in the
Gambia.

Methods: A mixed-methods approach, utilising focus group discussions, interviews, health
facility assessments, and workshops, explored adolescents’ SRH needs and service
engagement, the quality of services, and strategies for improvement. Qualitative data were
analysed thematically, descriptive statistics summarised quantitative data, and multivariate
logistic regression identified factors influencing perceptions.

Results: Adolescents in The Gambia recognise their need for SRH services such as
contraception, STI prevention, maternal health, GBV services, and sexuality education, but
these remain largely unmet. They rated these services as less accessible, appropriate, and
effective due to structural barriers (long waits, costs, overcrowding, weak referrals, poor
privacy) and sociocultural constraints like stigma, parental control, provider gatekeeping,
and taboos surrounding contraception, abortion, and FGM/C. Gender expectations worsen
inequalities: girls face surveillance, shame, and limited autonomy, while boys encounter
embarrassment and social stereotypes. Factors like income, education, marital status, and
residence influence perceptions, with rural adolescents often reporting more positive
experiences than their urban counterparts.
Providers acknowledged inequities but highlighted resource shortages, unclear guidelines,
and a lack of adolescent-specific SRH training. Many relied on moral judgment instead of
protocols for service delivery, which reinforced discrimination. The absence of adolescent-friendly
spaces, limited resources, and a focus on adolescent SRH reduced responsiveness.
Facility assessments revealed a low capacity for quality SRH services in urban sites, with
issues like medication stockouts, staff shortages, poor working conditions, and weak
infection control, even compared to rural facilities.
Participatory workshops revealed that adolescents prioritised confidentiality, trust, peer-led
models, and digital access, while adults focused on systemic reforms like policy, training,
and collaboration. Combining these views, the study co-developed a context-specific Theory
of Change (TOC) that operationalises WHO’s AFHS framework through a participatory,
locally validated systems model, directly connecting adolescent voices to service reform
pathways.

Conclusions: This study has contributed to a deeper understanding of adolescent SRH
service provision in The Gambia by considering access barriers as both systemic and
individual. It demonstrates how global best practices can be adapted to local contexts
through participatory engagement. Incorporating adolescent voices into health governance
and aligning services with their priorities will foster inclusive and people-centred responses
to adolescent SRH. The developed TOC offers a framework for integrating AFHS into the
Gambian national health systems.

Keywords: adolescent; access; adolescent-friendly services; sexual and reproductive health
accessibility; quality; The Gambia

Date of Award	20 Mar 2026
Original language	English
Awarding Institution	Liverpool School of Tropical Medicine
Supervisor	Nicola Desmond (Supervisor), Florence Mgawadere (Supervisor) & Mamady Cham (Supervisor)