The Health Belief Model (HBM) guided this study, providing a framework to understand adolescents’ resistance to preventive measures. Such resistance may relate to perceived susceptibility, severity, benefits and barriers. The model also considers cues to action, such as media exposure, and modifying factors, socio-psychological and structural, that may indirectly influence health behaviours.¹⁴

The study employed an explanatory sequential mixed-methods design, consisting of a quantitative cross-sectional descriptive survey, followed by a qualitative explanatory phase. The quantitative phase was conducted to identify factors influencing the uptake of AFHSs, whilst the qualitative phase explored participants’ views and experiences to explain and elaborate on the quantitative findings.

The Objectives-Goals-Strategies-Measures (OGSM) approach was applied¹⁵ with input from four experts in the fields of SRH and AFHSs, to guide the development of strategies. The OGSM framework helps convert objectives, goals, strategies and measures into practical and implementable action plans.

Based on the findings from phases one and two of the study, potential strategies to enhance access to AFHSs were developed.¹⁶ The initial strategies were reviewed and discussed with four experts in SRH and AFHSs, resulting in a consensus on nine agreed-upon strategies. The researcher and the four experts then refined these strategies before submitting them to 10 additional SRH and AFHSs experts for validation.

The study took place in four health facilities (referred to as health centres in Malawi) and their respective catchment areas within Blantyre District. Mdeka and Madziabango represented rural sites, whilst Ndirande and Chilomoni represented urban areas. Health centres form the backbone of primary health care, providing essential preventive, promotive, curative and rehabilitative services, including outpatient, maternal and child health, and AFHSs.

Phase one data were collected using a structured paper-based questionnaire, standardised for validity and reliability. Items were derived from the study objectives, literature and HBM constructs, and reviewed by experts for content and construct validity. The questionnaire was translated into Chichewa, back translated for consistency and pretested at the Gateway centre, resulting in minor revisions. Reliability was confirmed through internal consistency, and trained data collectors administered the tool.

Data collection took place from 20 September 2022 to 03 October 2022, with support from four trained research assistants. Each participant was given an information sheet to read prior to obtaining informed consent or assent. Those aged 18 years and above provided consent through a signature or fingerprint, whilst minors provided assent after their parents or guardians had obtained consent. Participants were informed of their right to withdraw at any time without penalty. Data were collected through interviewer-administered structured questionnaires by trained research assistants. This method was used because some adolescents were young or had limited literacy. Research assistants read questions aloud in the local language and recorded responses. All 288 targeted participants and five additional eligible adolescents completed the survey, yielding a 100% response rate.

The outcome variable in this study was uptake of AFHSs. Data were analysed using IBM^® Statistical Package for Social Sciences (SPSS) statistics. Descriptive statistics, including frequencies and percentages, were used to summarise participants’ characteristics and levels of AFHSs uptake. Bivariate analyses using Chi-square tests were performed to examine associations between AFHSs uptake and selected independent variables. Variables that showed significant associations at the bivariate level were entered into a multivariable logistic regression model. A binary logistic regression model was fitted to identify independent predictors of AFHSs uptake, with unadjusted and adjusted odds ratios (AORs), 95% confidence intervals (CIs) and p-values reported. Multicollinearity was assessed using the variance inflation factor (VIF) and tolerance values, with no evidence detected (VIF < 10, tolerance > 0.1). Model fit was confirmed using the Hosmer–Lemeshow test (p > 0.05).

Ethical clearance to conduct this study was obtained from the University of South Africa (UNISA) College of Human Science Ethics Committee (No. 67129765_CREC_CHS_2021). Ethical approval was obtained prior to the study, as research involving human participants must ensure the protection of their rights.²¹ The research proposal was reviewed and approved. Ethics approval is valid from 29 October 2021 to 29 October 2026. The research proposal was also submitted to the National Commission for Science and Technology of Malawi for ethical clearance (Ref No: NCST/RTT/2/6 PROTOCOL NO. P.08/22/663). Permission was also obtained from the Blantyre District Health Office, which oversees the four participating health facilities. Informed consent, parental consent or assent forms were reviewed with each participant, and signatures or fingerprints were collected from all respondents, including parents or guardians of participants under 18 years. Participants were assured of confidentiality, and all data were anonymised to protect their identities.

Phase two data were collected in October 2022 by the researcher and four trained assistants. Two tools were used: a semi-structured interview guide for individual interviews and a discussion guide for focus groups. Both were translated into Chichewa by a language expert. Six AFHS providers from the four health facilities were individually interviewed for 45 min–60 min. Three FGDs (N = 24) were conducted across three randomly selected centres. Each focus group had eight people. Each discussion lasted up to 1 h. All sessions were audio-recorded with participants’ consent.

The study revealed that only 43% of participants had ever accessed adolescent-friendly health services.

Overall, 66.2% of respondents (n = 194) were aware of AFHSs, mainly informed by friends (56.7%) and nurses (13.9%). For preferred sources of SRH information, nurses (45.7%) and parents (20.5%) ranked highest. However, 61.8% had never seen facility signage indicating AFHS availability, and 65.5% had never received printed reproductive health materials (Table 1).

Major barriers to AFHS access included shyness (86.1%) and fear of being seen at the facility (87.1%). Nonetheless, most respondents were satisfied with working days (86.7%), operating hours (93.1%), outreach services (87.6%) and facility cleanliness (92.2%). Notably, 96.9% reported that cultural and religious values were supportive of AFHS use (Table 2).

Cross-tabulations and Pearson’s Chi-square tests (α = 0.05, 95% confidence interval [CI]) identified key factors associated with AFHS uptake in Blantyre. As shown in Table 3, significant variables (p < 0.05) included gender, age, AFHS awareness, prior SRH education, presence of signposts and encouragement or discouragement to use services. Additional factors such as respectful provider attitudes, embarrassment and fear of being seen were also significant and included in subsequent analyses.

Multivariable logistic regression identified several key predictors of AFHS utilisation (Table 4). Adolescents’ demographic characteristics influenced uptake: males (Adjusted odds ratio [AOR] = 0.61, 95% CI: 0.37–0.98, p = 0.039) and those aged below 20 years (AOR = 0.19, 95% CI: 0.06–0.59, p = 0.001) were less likely to use AFHSs compared to females and older youths, respectively.

Knowledge and awareness-related factors strongly increased utilisation. Adolescents who were aware of AFHS services (AOR = 28.61, 95% CI: 10.99–74.45, p < 0.001), exposed to SRH information (AOR = 2.72, 95% CI: 1.39–5.32, p = 0.002), noticed service signs (AOR = 5.58, 95% CI: 3.14–9.91, p < 0.001) or received SRH informational materials (AOR = 3.74, 95% CI: 2.17–6.44, p < 0.001) were significantly more likely to utilise the services. Encouragement from others had the strongest effect (AOR = 52.26, 95% CI: 15.41–177.19, p < 0.001).

Attitudinal and facility-related factors also played a role. Adolescents who were reluctant due to shyness (AOR = 0.37, 95% CI: 0.16–0.83, p = 0.012) or feared being seen (AOR = 0.38, 95% CI: 0.16–0.88, p = 0.020) were less likely to use AFHSs, whereas respectful treatment by providers increased uptake (AOR = 6.34, 95% CI: 1.28–31.43, p = 0.009).

Data from individual interviews and FGDs were analysed using Braun and Clarke’s thematic analysis approach, following their six-step framework as outlined in their 2006 publication.¹⁶ Two researchers independently coded transcripts, compared their interpretations and refined themes through a consensus process. Reflexivity was maintained through peer debriefing and the documentation of analytic decisions, which enhanced the trustworthiness of the research.

The demographic profile of the youth participants (N = 24) included an equal number of males and females in each focus group. Each group consisted of eight members – one male and one female from each of the following age groups: 10 years – 12 years, 13 years – 16 years, 17 years – 20 years and 21 years – 24 years. All youth participants were unmarried.

For the individual interviews, participants were all aged above 24 years. Amongst them, five were female and one male, with one participant being married. All were identified as Christians. Two participants had tertiary education and were nurses, whilst two had completed secondary education. Only one participant had received formal training in delivering AFHSs; the others had been given only on-the-job orientation. All had worked at a AFHS facility for more than a year, with one having over 7 years of experience.

Thematic analysis of verbatim transcripts from both individual interviews and FGDs yielded six key themes. A summary of these themes, along with their corresponding sub-themes, is presented in Table 5.

The nine strategies were informed in phase three by both quantitative and qualitative data: Daily services, youthful and gender-diverse providers, dedicated spaces and flexible hours, addressed accessibility and comfort, supported by survey results and the expressed preferences of adolescents. Awareness campaigns, recreational activities, outreach services and parent engagement highlighted gaps in knowledge, engagement and family support, underscoring the need for an evidence-based, youth-centred approach to improving AFHSs uptake. (Refer to Figure 1 for the strategies.)

The developed strategies incorporated novel, context-specific elements that extend beyond existing national guidelines. These included the integration of entertainment and recreational activities within AFHSs settings (S4), enhanced awareness initiatives to inform adolescents about available services (S2) and the provision of services daily rather than on select days (S1). Participants further emphasised the importance of dedicated service spaces (S5), engagement of youthful providers (S6) and the presence of both male and female staff to accommodate gender preferences (S7).

The study’s findings may have limited generalizability beyond the study context. Nonetheless, the findings provide valuable insights into strategies that could enhance the uptake of AFHSs, offering useful guidance for policymakers aiming to improve access and uptake of these services. The use of self-reported data may have introduced recall and social desirability bias, given the sensitive nature of SRH questions. Additionally, some variables exhibited wide confidence intervals (e.g. encouragement AOR = 52.26), likely due to small subgroup sizes and potential model overfitting, and should therefore be interpreted with caution.

The findings from this study highlight the importance of targeting both male and female adolescents in efforts to promote the uptake of AFHSs. Whilst girls are often more directly affected by the consequences of unintended pregnancies, it is equally important for boys to be well-informed about reproductive health to support prevention efforts. Greater attention should also be given to younger adolescents, who are at a higher risk of experiencing complications from early childbearing.

Given that most adolescents are still in school, there is a need for policies that integrate comprehensive SRH and AFHSs information into both primary and secondary education. Additionally, establishing youth clubs in remote areas where access to government health facilities is limited could help bring services closer to the community. These clubs could serve as points for AFHS delivery, with trained service providers visiting at least once a month to offer support and care.

There is also a clear need to expand SRH education and awareness efforts across multiple platforms, including schools, youth clubs, outpatient departments of health facilities and community settings. Mass media channels, such as radio and television, can be powerful tools in spreading SRH messages, especially when supported by the Ministry of Health in collaboration with Non-Governmental Organizations (NGOs) that focus on adolescent health.

Furthermore, the study emphasises the importance of deploying trained, adolescent-friendly service providers in AFHSs. Such professionals are better equipped to offer respectful, supportive and non-judgemental care, which in turn encourages greater adolescent engagement with these services.