A scoping review of strategies for adolescents’ sexual and reproductive health role modelling

Background Individuals strive to maintain their sexual and reproductive health (SRH) by being exposed to correct information, having access to contraceptives, and promoting safe sex practices. Adolescent SRH promotion efforts should consider the influence of role models. This review explored the availability and nature of strategies and programmes on adolescents’ SRH role modelling and described them using a scoping review. Methods Studies were retrieved from four databases and grey literature through a search of 223 studies. The databases included EBSCO-host, Medline, Sabinet, and Pubmed. Data extraction was guided by a data-extraction tool adapted from the JBI Manual for Evidence Synthesis. The characteristics of the selected studies were recorded in a Microsoft spreadsheet. Eleven studies published between 2014 and 2022 were included for the final review and analysed using thematic analysis. Results Selected articles focused on adolescents’ SRH; however, only two studies focused particularly on role modelling. Nonetheless, some aspects of the findings and recommendations presented could be extrapolated to adolescents’ SRH role modelling. This includes adolescent–parent communication on SRH, community engagement, mentoring, positive role modelling, and information sharing through media campaigns. Conclusion There is a lack of literature on SRH role modelling because most studies did not focus on role modelling as an aspect of SRH. Therefore, research needs to be conducted on strategies and programmes focusing on SRH modelling. Contribution The findings of this scoping review may encourage the development and implementation of strategies and programmes targeting adolescents’ SRH throughout diverse communities to promote adolescent SRH.


Introduction
Adolescents sexual and reproductive health (SRH) refers to a state of total well-being in all aspects of the reproductive system, including physical, mental, and social health of people between the ages of 10 and 19 years. 1,2The United Nations Population Fund (UNFPA) further explains that individuals strive to maintain their SRH by being exposed to correct information, having access to contraceptives, and promoting safe sex practices. 1For adolescents, maintenance of their SRH happens at a time when they are discovering and establishing their sexual and reproductive developmental changes.Sanci et al. 3 suggested that because of these changes, adolescents recognise the connection between behaviour and consequences to a lesser extent, and may believe that they are invincible, leading to experimenting with drugs, and alcohol, as well as engaging in sexual activity early in life.
The World Health Organization (WHO) posits that SRH changes happen during a turbulent period in adolescents' lives, where they are at risk of adolescent pregnancies and early parenthood, which perpetuates outcomes such as poverty and poor education attainment in adulthood. 4Likewise, during this time young people tend to take more risks, especially sexual risks, which can have serious implications such as unwanted pregnancies or sexually transmitted infections (STIs). 5Adolescent pregnancies have been a problem for developing and sub-Saharan countries; for instance, in 2021 it was estimated that 14% of adolescent girls had given birth before they turned 18 years globally. 6In the United States (US) it was reported that in 2020 around 15% of all live births among 15 to 19-year-olds were at least the mother's second child. 7

A scoping review of strategies for adolescents' sexual and reproductive health role modelling
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Sexual and reproductive health role models refer to individual adolescents who look up to and aim to imitate their behaviours because they see it as desirable; such behaviour may be positive or negative. 12Price-Mitchel 13 reiterated that role models are often seen as people who exhibit exceptional traits, such as the capacity to uplift others, communicate moral principles, and overcome challenges, however, they can have either a positive or negative influence on adolescents.Role models such as parents display characteristics that can influence adolescents' behaviour, such behavioural influence depends on parent-child communication, the degree of closeness between them, monitoring and supervision, and transmission of values and knowledge. 14Munea et al. 15 studied adolescent SRH from a sociocultural context.They asserted that sociocultural factors influence adolescents' experiences, behaviour, and decision-making, such sociocultural factors are transmitted from the community and the society.Role modelling on the other hand plays a major role in how adolescents' behaviour is influenced by these socio-cultural factors.Role models, as members of the community can be imitated by adolescents who may be regarded as impressionable.Furthermore, influences may also come from the communication styles and the content that is being communicated between adolescents and their role models.
In South Africa, adolescents' SRH rights policies advocate for effective community supportive networks, quality health services, screening for STIs, counselling, and education for adolescents. 16The researcher has observed that there is a significant gap in the literature regarding the position of role models in SRH support and the influence of adolescents in the South African context.Literature on this phenomenon mostly originates from countries such as the US and some European countries. 11,17Sexual and reproductive health role modelling has not been explored in the South African context.Therefore, the study aimed to explore the availability of strategies and programmes on adolescents' SRH role modelling using a scoping review.

Objectives of the study
• To explore the availability of strategies and programmes on SRH role modelling using a scoping review and describe them using a scoping review • To investigate the scope and quantity of literature on adolescents' SRH role modelling

Review questions
• What is the availability and nature of strategies and programmes on adolescents' SRH role modelling?• What is the scope and quantity of literature on adolescents' SRH role modelling?

Methodology
The study was conducted using a qualitative scoping review.
A scoping review is a type of literature review that is used for evidence synthesis to systematically identify and map the availability of information on a particular topic or concept in a broader context. 18,19The scoping review in this study was conducted according to the methodological framework outlined by JBI by Peters et al. 20 JBI Manual for Evidence Synthesis highlights that, unlike extensive systematic reviews, scoping reviews aim to provide an overview of the literature available on a certain topic. 21The JBI framework recommends that in a scoping review, the researcher must outline the review objective, questions, eligibility criteria, search strategy, evidence screening and selection, data extraction, and analysis of evidence, presentation of results and summary of evidence with the purpose of the review. 20

Eligibility criteria
Inclusion and exclusion criteria were formulated to refine and give relevant data and all criteria were applied to all search engines and databases.Studies that were eligible during the search included full journal articles, systematic reviews, official reports, dissertations, and theses, grey literature, studies that were published in English, studies that were published between 2013 and 2023, and both qualitative and quantitative research studies.Guidelines and policies were also consulted but there was no literature found.Studies that were not eligible for inclusion were articles that did not discuss adolescents' SRH role modelling, abstracts, editorial, clinical reviews, and conceptual articles.

Search strategy
The literature search included browsing through databases in search of articles that contain information on strategies and programmes for SRH role modelling.

Evidence screening and selection
After the search, all discovered citations were collected and imported into the Mendeley reference manager program.The references were then imported into the Rayyan software to manage and organise the selected sources for the scoping review and eliminate duplicates. 22The titles and abstracts were evaluated by the researcher and one reviewer who compared them to the researcher's inclusion criteria.The full text of any potentially pertinent sources was obtained and their citation information was incorporated.The researcher and reviewer carefully evaluated the complete text of the chosen citations about the inclusion criteria.The scoping review noted and documented the reasons for excluding full-text sources of evidence that do not fit the inclusion criteria.At each level of the selection process, any discrepancies that arose between the researcher and the reviewers were handled through discussions.

Charting the data
Data extraction or data charting summarises the results logically and descriptively, and it reveals the alignment between the results and the objectives or questions of the scoping review. 21The data that were extracted focused on literature about adolescents' SRH role modelling.The data extraction or charting process was guided by a data-extraction tool adapted from the JBI Manual for Evidence Synthesis. 21he tool was used to extract details from the articles, such as authors, year of publication, source details, methods, and key findings that relate to the scoping review as reflected in Table 4. Data capturing was performed using a Microsoft Excel spreadsheet to record the counts, participants' details, characteristics of data, methods, context, citation details, country, and the summary of findings related to adolescents' SRH role modelling.

Analysis of evidence
Data were analysed according to the three steps proposed in the framework by Arksey and O'Malley. 23The first step included an analytic framework using the PRISMA-ScR flow chart to provide an overview of the breadth of the literature regarding the strategies for SRH role modelling.The second step included a descriptive statistical analysis using tables to present the kind of studies selected.The descriptive statistics reported on types of publications of sources, year of publication, and the origin of the studies by country, are presented in Table 1, Table 2, and Table 3.In the third and last step, thematic analysis was used to select themes related to strategies and programmes focusing on adolescents' SRH role modelling.
The themes that emerged during the analysis were discussed in detail to reflect the description of SRH role modelling.

Ethical considerations
The

Results
Articles were retrieved from four databases and grey literature through a search of 223 studies.Fifty-seven duplicates were then removed, which resulted in 166 studies   being available for abstract reading.The inclusion and exclusion criteria were applied to select relevant studies for the scoping review.A total 105 records were then excluded for failing to meet the inclusion criteria after reading the title and abstract, which left 59 records for full-text reading and eligibility.As there is little literature about SRH role modelling, 42 studies were excluded for being out of scope and focusing on adolescent SRH in general without role modelling strategies or programmes.Furthermore, six studies were unavailable for full-text reading.Lastly, 11 studies were then included for the final review.The process of selecting the studies is presented in Figure 1 adapted from the PRISMA flow chart. 24

Article summary characteristics
The characteristics of the selected articles are presented in Table 1, Table 2, Table 3, and Table 4.The 11 selected articles were published between 2012 and 2023.Table 1 presents the years of publication for the selected articles, five articles (n = 5) were published between 2020 and 2022, two studies (n = 2) between 2019 and 2021, and four studies (n = 4) between 2014 and 2015.The types of publication of sources in Table 2 indicates that most studies were qualitative (n = 5), then mixed method studies (n = 2) and review studies (n = 2) were two each.Lastly, there was only one theoretical article (n = 1) and one quantitative study (n = 1).Most studies focusing on SRH role modelling originate from the US (n = 4), two originate from Ethiopia (n = 2), and the rest originate from Nigeria (n = 1), Tanzania (n = 1), Malawi (n = 1), Cambodia (n = 1), and Chile (n = 1) (see Table 3).

Emerging themes from the selected studies
The selected studies yielded five themes: adolescent-parent communication on SRH, community engagement, mentoring, positive role modelling, and information sharing through media campaigns.The themes identified were extrapolated to describe strategies applicable to SRH role modelling.However, the themes should not be conflated with SRH role modelling.

Theme 1: Adolescent-parent communication on sexual and reproductive health
Adolescent parent communication is the most common strategy for adolescent SRH role modelling found in the selected studies.Parent-adolescent communication and parental involvement were proposed as some of the strategies

Mixed method
The study is about an adult programme for role models for adolescents' SRH.The ARM programme is curriculum-based and led by trained parent-peer educators in community settings.The four-workshop weekly 2-h sessions were highly feasible and acceptable to the parents in our study, as evidenced by high attendance rates, satisfaction, and interest in the programme.Descriptive qualitative and quantitative data revealed high levels of acceptability and feasibility for parent participants.Participants travelled near and far by public transportation within the Bronx to attend the groups.Many participants noticed that our provision of food and cash incentives was helpful.Furthermore, the curriculum was conducted with a high level of fidelity and facilitator quality.Exploratory, small-scale RCT data show promising parent outcomes for frequency of communication, monitoring, and connectedness with children, and increases in knowledge about sexuality and adolescent development.We look forward to comparing youth reports related to the ARM intervention and conducting a larger-scale RCT in the future.Most analytic effects were interactions between group and time, such that as ARM intervention participants increased across outcomes, even if not as a significant main effect, control participants decreased.One explanation may be that the ARM intervention group parents practised skills over time and thus experienced more positive parent-child outcomes as their teens progressed through developmental stages that may have created more challenges for control group parents.This research adds to the small, but growing, literature on the importance of parent sexuality education and its impact on adolescent sexual and reproductive health.We present a new curriculum model that is highly feasible and acceptable and can be performed with fidelity.Results demonstrate promising parent outcomes for frequency of communication, monitoring, and connectedness with their children, and increases in knowledge about sexuality and adolescent development.

Svanemyr et al. (2015)
Creating an enabling environment for adolescent sexual and reproductive health: A framework and promising approaches

Review
This study provides relevant strategies that can be adopted and used as SRH role modelling strategies.The strategies include Creating safe spaces for adolescent girls, parental engagement, mentoring, and positive role modelling, mobilisation of adults and community leaders, working with boys and encouraging men to promote gender-equitable norms, Media campaigns, and large-scale communication programmes, and promoting laws and policies and their implementation.included in SRH programmes. 26Such strategies promote and advocate for a community-based awareness approach in addressing SRH issues among adolescents.This was supported by another article that shared the same sentiments about adolescent-parent communication as an impactful strategy to address adolescent SRH.Parents use their knowledge and experience to guide adolescents in making the right decision and they usually occupy the role model status. 27xual and reproductive health programmes focusing on parent-youth relationships encourage parents to communicate with their adolescents about sexual behaviour and romantic relationships, which may be an effective strategy for SRH role modelling. 27Furthermore, it was recommended that funded SRH projects in Ethiopia focus on parental engagement and adolescent-parent communication in SRH issues, as well as the facilitation of activities around this topic. 28Despite numerous studies advocating for adolescent-parent communication as an effective strategy to improve adolescent SRH, there are also challenges identified in applying the strategy.The main difficulty impeding the effectiveness of this strategy is the content shared by parents with their adolescents. 29The content shared by parents contains strict warning messages to adolescents and the advice given during such conversations is often unclear. 29Parents need to acknowledge their position as important role models to their adolescents.Moreover, parents must be continuously capacitated to improve their knowledge to communicate effectively with their children. 28The importance of the early beginning of SRH communication between adolescents and parents should be emphasised. 29

Theme 2: Community engagement
Community engagement is a strategy that can be applied in SRH role modelling because community members play a critical role in influencing the health choices of adolescents.Community-based SRH programmes are important to create awareness and educate community members to be proficient members when it comes to the lives of adolescents. 26,30his applied to role modelling because educating community members and respected community people to lead community-based informal education initiatives would help to increase SRH understanding while minimising common misconceptions and inaccuracies in the community. 30urthermore, role models such as family members and female community members were regarded as the source of information for female adolescents when it came to SRH. 30 There are roles that community members occupy in promoting adolescents' SRH, these roles include guidance, encouraging, regulating, and banning cultural customs, drafting ordinances, and addressing sexual abuse complaints. 31tudies that supported this notion affirmed that community leaders are responsible for teaching adolescents about social issues such as social norms, gender-equitable norms, and sexual behaviour. 25,32Moreover, community religious leaders play an important role in imparting knowledge and information from a religious narrative. 31

Theme 3: Mentoring and positive role modelling
Mentoring and positive role modelling are essential in ensuring that adolescents imitate positive SRH choices in their daily lives.Creating safe spaces for adolescent girls, parental participation, mentoring, positive role modelling, mobilisation of adults and community leaders, engaging with boys, and motivating males to promote genderequitable norms were among some of the strategies identified. 25Community members such as parents, religious leaders, teachers, siblings, relatives, and healthcare workers can all act as positive role models in the community.Schoolbased SRH programme for adolescents in Chile promoted permanent and expedited access to SRH care, and affectionate bonds formed between students and the programme's health personnel. 33This implies that through the bonds, positive role modelling can emerge between adolescents and health personnel.Adolescents in the schoolbased programme were allowed to improve their SRH by learning about SRH decision-making, self-care, and being responsible in sexual and emotional relationships. 33study by Colarossi et al. 17 reported on an adult program for role models for adolescents' SRH.The curriculumbased programme is a 4-week workshop led by parent-peer educators in the community. 17Data from the study suggest that encouraging parent outcomes in terms of frequency of communication, monitoring, and connectivity with children improves knowledge about sexuality and adolescent development. 17A study focusing on caregiverendorsed strategies to improve SRH outcomes among youth suggested several strategies for positive role modelling and mentorship. 34The strategies include communicating with youth about sexual health, monitoring youth, and other positive youth development, training that teaches caregivers about sexual health and normal adolescent development, as well as strategies and skills to help caregivers engage in open, evidence-informed communication and monitoring of adolescents. 34

Theme 4: Information sharing, media campaigns
Information sharing regarding SRH can come in various ways, including the use of media as a tool to reach many people.Continuous capacity building can improve the SRH knowledge of potential role models such as parents. 28nowledge improvement is imperative because it means that role models can then impart accurate, relevant, and clear information to adolescents. 28This is supported by Albertson et al. 33 who reiterated that training teaches parents about sexual health and normal adolescent development and improves their skills to help them engage in open, evidence-informed communication with adolescents, which improves their reproductive health outcomes.Recommendations to improve information sharing regarding adolescents SRH, included promoting laws and policies, as well as their implementation, through media campaigns and large-scale communication programmes. 25ttps://www.safpj.co.za Open Access

Discussion
This scoping review mapped out the availability of literature and strategies on adolescents' SRH role modelling.The results of the scoping review indicate that there is an unavailability of literature focusing on SRH role modelling.However, there are a few studies that contain strategies for SRH role modelling, and such studies focus on adolescents' SRH in general.The four themes identified focus on different aspects of addressing SRH role modelling in communities.However, within each theme, communication seems to be the most common strategy to address adolescent SRH.In addition, the themes suggest that the link between role models in the community and adolescents stems from the notion that adolescents often lack knowledge regarding SRH issues.
Adolescent-parent communication is one of the most common strategies to address SRH modelling.The parental bond with their adolescent has a significant role in paving the route for them, both parent and adolescent must have a favourable level of understanding and progress towards a more approachable connection. 35It is important to involve parents and caregivers as crucial partners in nurturing and supporting healthy adolescent development, particularly when it comes to issues concerning their SRH choices. 36arents in some instances assume the role model status because they are close to adolescents and they spend most of their time with them at home.Therefore, parents become the primary source of information, making the content that they share with adolescents very important.
Parents and caregivers assume role model status when they engage in positive conversations and offer guidance to adolescents so that they can make informed SRH choices.Furthermore, Kapetanovic et al. posit that parent-adolescent communication can provide a comfortable atmosphere for adolescents to willingly speak with their parents about their daily activities and life plans.However, it is not always easy for parents to communicate with adolescents about their daily activities and SRH because parents do not know what to say in some cases. 29Conversely, when adolescents provide information about their whereabouts and activities, parents have more possibilities to guide and encourage them to make the right choices. 37rents and caregivers remain the primary people who offer guidance and support to adolescents, however, the whole community must be involved in addressing the SRH of adolescents.In Zambia, using community-led strategies to provide information on the responsiveness to adolescents' SRH and promoting adolescent access to SRH information improved the lowering of early pregnancy and marriage rates, as well as maternal, neonatal, and child health. 38hese community-based strategies to promote SRH role modelling can be fostered by community-based role models such as parents, teachers, religious leaders, and healthcare providers.These community members are highly regarded by adolescents and can help shape their SRH behaviour by providing health information to them. 31Furthermore, community leaders in Malawi were reported to have contributed to the reduction of maternal mortality in Malawi because they make decisions and govern cultural practices and beliefs in their communities. 31The choices made by community leaders directly impact the actions of adolescents because of the influence related to the cultural practices, cultural norms, and values in communities.Information sharing between adolescents and community role models may be hindered by the lack of role-modelling-focused initiatives in the community.Moreover, community-based role models such as parents, teachers, and community leaders may lack the relevant resources to facilitate different information-sharing and media campaigns focusing on SRH health content.This may suggest that members of the community also need to be capacitated so that they are able to play their SRH role modelling role.

Conclusion
The scoping review aimed to explore the availability of strategies and programmes on adolescents' SRH role modelling and describe them using a scoping review.The scoping review revealed that there is a lack of literature on SRH role modelling because most of the studies found did not focus on role modelling as an aspect of SRH.However, the findings and recommendations from the selected studies highlight strategies that can be extrapolated and used in addressing SRH rolemodelling efforts in communities.The extrapolations only from the themes initiate a conversation regarding strategies for adolescents' SRH role modelling and should not be conflated.The findings of the scoping review revealed common strategies and programmes that can be used for SRH role modelling, this includes programmes and strategies focusing on adolescentparent communication on SRH, community engagement, mentoring, positive role modelling, and information sharing through media campaigns.Furthermore, this review highlights the gap in research and literature regarding SRH role modelling.Therefore, it is recommended that more research needs to be conducted on strategies and programmes focusing on SRH modelling.Strategies and programmes targeting adolescents' SRH role modelling need to be developed and implemented throughout diverse communities to promote adolescent SRH.Moreover, communication strategies and programmes could provide opportunities to promote and cultivate SRH role modelling.

Limitation
The following are the limitations of this review: • 'Sexual and reproductive health role modelling' is a relatively new concept, therefore, there was only one study that focused particularly on this concept.Other studies included concepts that can be applied to SRH role modelling.• This review included only four databases, however, there are many more databases available.Using four databases may have led to a selection bias in this study.
• This scoping review did not include a full appraisal of the selected studies, which limited the extent of the argument the selected studies contribute to strategies on SRH role modelling.• The identified strategies were not tested for effectiveness and applicability.• Because of the scarcity of studies, this is a limited scoping review.

Source: 4 FIGURE 1 :
FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Review flow chart for selection of studies.

TABLE 3 :
Origin of studies by country.

TABLE 2 :
Type of publication of sources.

TABLE 1 :
Year of publication.

TABLE 4 :
Summary of sources.or programmes focus on SRH role modelling, however, some aspects of the article can be extrapolated.The article advocates for community-based awareness programmes, engaging community influences, and parents, and promotion of youth friendly services to address SRH of adolescents.Furthermore, the article encourages parent-adolescent communication and parental involvement in adolescents' SRH programmes.or programmes focus on SRH role modelling, however, some aspects of the article can be extrapolated.This article highlights the importance of parent-child communication: an event that rarely occurs.SRH content shared by parents consists of strict warnings and ambiguous Parents need to be reorientated to communicate better with adolescents.Early initiation of SRH communication was highlighted.or programmes focus on SRH role modelling, however, some aspects of the article can be extrapolated.Most of the interventions addressed multiple structural factors, such as social norms, gender inequality, and poverty.Some interventions focused on reducing economic drivers that increased sexual risk behaviours.Others focused on changing social norms and thus sexual risk behaviours through communication.Social norms addressed included gender inequality, gender violence, and child socialisation.The interventions included components of comprehensive sexuality and behaviour change and communication and parenting.or programmes focus on SRH role modelling, however, some aspects of the article can be extrapolated.This article highlights that community leaders have many roles in adolescent HIV and SRH.These roles include advisory, encouragement, regulating and restricting cultural practices, formulating bylaws, and handling sexual abuse complaints.However, community leaders with religious affiliations have been shown to have different views from those representing other institutions not affiliated with religion.or programmes focus on SRH role modelling, however, some aspects of the article can be extrapolated.The study highlights parent-to-adolescent discussion on reproductive health issues as the basis for a safe and healthy transition to adulthood.Continuous capacity building regarding SRH for parents is recommended to improve their knowledge support and increase the reach of the adult learning programme to decrease the level of illiteracy.Another recommendation would be to engage health providers with the tools and job aids to help them discuss the importance of parent-adolescent communication on SRH issues and include activities around this topic in donor-funded AYRH projects in Ethiopia.
QuantitativeNo specific strategies or programmes focus on SRH role modelling, however, some aspects of the article can be extrapolated.(1) Strategies to communicate with youth about sexual health (trust-building, open/ direct communication, tailoring information to each youth, creative conversation-starters, and selfeducation), (2) strategies for monitoring youth (e.g.tailoring monitoring to youth development/ characteristics, clearly communicating rules, co-development of rules, spending time with youth/friends/ friends' parents, using technology, using a social support system), and (3) other strategies to promote positive youth development (advocating for youth, engaging youth in goal setting).Training that provides caregivers with (1) information on sexual health and normal adolescent development and (2) strategies and skills to help caregivers engage in open, evidence-informed communication, and monitor youth in a tailored, developmentally informed manner are likely to improve reproductive health and other outcomes among youth in foster care.
Permanent and expedited student access to sexual and reproductive healthcare is achieved, and affectional bonds are developed between students and the program's health staff.The programme assists female participants in imagining and forming identities that are not inherently tied to motherhood.It also assists boys and LGBTQ+ adolescents in feeling included as relevant actors in sexual and reproductive health and decision-making.According to participants, the affectivity and sexuality component of the programme encourages self-care and responsibility in sexual and emotional relationships.Effective dialogue, communicating one's feelings, and caring for the feelings of others, are the focus of the programme.3A it also encourages encourages reflection on gender stereotypes and norms regarding sexuality.