To map and synthesise evidence on the multi-level determinants of inequalities in upstream adolescent SRH outcomes and service utilization in sub-Saharan Africa.

Primary review question

What evidence exists on the multi-level determinants of inequalities in upstream adolescent SRH outcomes and service utilisation in sub-Saharan Africa?

Secondary questions

A. Inequalities in SRH outcomes

B. Inequalities in SRH service utilisation

C. Methodological and evidence gaps

This scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (Aromataris & Munn, 2020; Peters et al., 2020) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; Tricco et al., 2018). Scoping review methodology is appropriate here because the aim is to map the breadth and characteristics of available evidence across a heterogeneous literature, rather than to synthesise findings from methodologically homogeneous studies or to answer a specific clinical effectiveness question (Arksey & O’Malley, 2005; Munn et al., 2018).

The protocol has been informed by the Joanna Briggs Institute (JBI) methodology for scoping reviews and the PRISMA-ScR checklist (Peters et al., 2024). In order to ensure transparency, reproducibility and methodological consistency this protocol is registered on the Open Science Framework (OSF), available at https://osf.io/p7crz n.

The inclusion and exclusion criteria will be defined based on the were PCC (Population, Concept, Context) framework. Population: the population will cover adolescents aged 10–24 years, with sub-analysis by age cohort: 10–14, 15–19, and 20–24 years where data permit. If sufficient literature is identified, the focus may be refined to adolescents aged 10–19 years. These groups have meaningfully different SRH experiences, risk profiles, and service utilisation patterns (Blum et al., 2017; Patton et al., 2016). Early adolescents are generally less sexually active but are in critical formative periods for SRH education and behavioural norms. Service utilisation data from comparable SSA settings indicate that the highest rates of SRH service use typically occur among those aged 15–19 (ICF International, 2023). If the volume of available literature supports a more focused analysis, the review may be refined to adolescents aged 10–19 years, with young adults (20–24) included only where their exclusion would substantially limit the evidence base.

Concept: The concept will that will guide the study will among others include inequalities in upstream adolescent SRH outcomes (encompassing family planning and contraceptive access, STI/HIV prevention and care, sexual health education, and adolescent pregnancy occurrence and determinants) and inequalities in SRH service utilisation, including determinants of access, utilisation, and quality of services.

The context of the study will be on Sub-Saharan Africa (SSA) countries. A secondary sub-regional analysis focusing on West Africa will be considered if sufficient literature is available. The primary geographic scope is sub-Saharan Africa (SSA), defined in accordance with the United Nations geoscheme (United Nations Statistics Division, 2023). This scope reflects the availability of a substantial body of adolescent SRH literature and the regional coherence of policy and programmatic contexts. If a sufficient concentration of evidence is identified from West African countries specifically, a secondary sub-regional analysis will be conducted. This is particularly relevant given the primary practice context of this research in Sierra Leone, which shares closer political, cultural, and health system characteristics with neighbouring West African nations than with other SSA sub-regions. A Sierra Leone-specific analysis alone would be unlikely to yield sufficient literature for meaningful synthesis, and broadening to West Africa or SSA provides a more generalisable evidence base.

The inclusion and exclusion criteria will be defined by using the PCC (Population, Concept, Context) framework. This is recommended by JBI for scoping reviews (Peters et al., 2020). Inclusion criteria are presented in Table 1 and exclusion criteria in Table 2.

A systematic literature search will be conducted using pre-specified, database-adapted strategies combining Medical Subject Headings (MeSH) terms and free-text keywords. The search strategy was developed iteratively with reference to established guidance for scoping reviews (Arksey & O’Malley, 2005; Levac et al., 2010) and informed by a preliminary review of the existing literature. Searches will be conducted in August, 2026 and updated if more than six months elapse before manuscript submission, consistent with best practice (Garritty et al., 2021). Publications from January 2015 to June 2026 will be included. This eleven-year window was selected to reflect the contemporary evidence base relevant to current policy and programme contexts in SSA, including the period since the adoption of the Sustainable Development Goals (SDGs) in 2015, which elevated adolescent SRH as a global priority (United Nations, 2015). Figure 1 presents the conceptual search framework as a Venn diagram of four intersecting eligibility domains. Only studies falling within the intersection of all four domains (population, SRH focus, inequalities and determinants, and geographic focus) will be eligible for inclusion in this review.

A systematic literature search will be conducted in PubMed, African Journal Online, Google Scholar, Demographic and Health Survey publications and Country reports as well as Reference list searching.

Timeframe

Publications from January 2015 to June 2026 will be included. This eleven-year window was selected to reflect the contemporary evidence base relevant to current policy and programme contexts in SSA, including the period since the adoption of the Sustainable Development Goals (SDGs) in 2015, which elevated adolescent SRH as a global priority (United Nations, 2015).

Search strategies have been developed and will be adapted for each database. Truncation (asterisk, *) is used to capture variant spellings and word endings in Medical Searching Headlines (MeSH). Boolean operators (AND, OR) will be used in order to connect various terms across conceptual domains. All MeSH terms have been verified against the NLM MeSH browser. The strategy is structured in four concept blocks corresponding to the eligibility framework. The combined strategy as presented in Table 3 below is: Block 1 AND Block 2 AND Block 3 AND Block 4. The study will adopt advanced search options in Google Scholar where available. Screening will continue until ten consecutive irrelevant titles are encountered per string.

Search results will be exported in CSV format and managed in Zotero. Deduplication and screening will be conducted in Rayyan, a web-based systematic review platform (Ouzzani et al., 2016).

Screening will be conducted in four sequential stages. All decisions will be recorded, with reasons for exclusion documented at the full-text stage. Inter-rater reliability will be assessed at each stage using Cohen’s kappa (Cohen, 1960), with a minimum acceptable agreement of κ ≥ 0.70 prior to proceeding. The screening and selection process is illustrated in Figure 2.

Stage 1: Deduplication

Duplicate records identified across databases will be removed in Rayyan prior to any screening.

Stage 2: Title screening

Titles will be assessed against three gatekeeping criteria: (i) Is the study focused on adolescents or young people? (ii) Is the study conducted in sub-Saharan Africa? (iii) Is the study relevant to SRH outcomes or services?

Stage 3: Abstract screening

Abstracts of title-eligible records will be assessed for relevance to upstream SRH outcomes or service utilisation inequalities and their determinants, and for alignment with the full eligibility criteria.

Stage 4: Full-Text screening

Full texts of all potentially eligible studies will be retrieved and assessed against all inclusion and exclusion criteria. This stage constitutes the definitive eligibility decision. Any study for which the full text cannot be retrieved will be recorded as excluded, with reason noted. All stages will be completed independently by two reviewers. Disagreements at any stage will first be resolved through discussion and consensus. Where agreement cannot be reached, a third reviewer will adjudicate. This three-reviewer arbitration approach is consistent with JBI scoping review guidance (Peters et al., 2020).

In keeping with standard scoping review methodology, no formal quality appraisal of included studies will be conducted (Arksey & O’Malley, 2005; Munn et al., 2018; Peters et al., 2020). The purpose of this review is to map the breadth and characteristics of available evidence rather than to appraise the methodological quality of individual studies. Study design and methodological approach will, however, be recorded as descriptive variables during data extraction and reported in the synthesis.

Data will be extracted from all included studies using a standardised charting form, adapted from the JBI scoping review data extraction template (Peters et al., 2020). The form will capture: first author and year; country; study design; sample size and population characteristics (including age, sex, and geographic setting); SRH domain(s) addressed; level(s) of determinants examined (structural, sociocultural, health system, institutional); whether findings relate to SRH outcomes, service utilisation, or both; key findings relevant to inequalities; any interventions described; and reported barriers to intervention effectiveness. The form will be piloted on a random sample of five to ten included studies and refined before full extraction. Data extraction is planned for September, 2026.

Results will be presented using a PRISMA-ScR flow diagram documenting the search and selection process (Tricco et al., 2018). Evidence will be synthesised thematically following the analytical framework presented in Figure 3, organised around two parallel tracks: (A) determinants of adolescent SRH outcomes, and (B) determinants of SRH service utilisation. Within each track, findings will be grouped by level of determinant: structural, sociocultural, health system, and institutional. Interactions across levels and the conceptual overlap between the two tracks will be discussed analytically. This thematic approach follows established scoping review synthesis methods (Arksey & O’Malley, 2005; Levac et al., 2010).

Descriptive summaries of study characteristics, including study design, country, SRH domain, and age group, will be presented in tabular form. DHS-based evidence will be reported as a distinct evidence stream highlighting nationally representative patterns of inequality. Where studies report on existing interventions, information on intervention type and documented implementation barriers (including distance to services, acceptability, availability, and cultural factors) will be reported narratively as a supplementary finding.

This scoping review will draw exclusively on published data from existing peer-reviewed literature and publicly available reports. No primary data collection involving human participants is planned. Ethical approval is therefore not required, consistent with guidance from the JBI and standard practice for secondary data reviews (Peters et al., 2020).

The findings of this scoping review will be submitted for publication in a peer-reviewed journal. Results will also be disseminated through academic conferences and national and global policy forums relevant to adolescent SRH in SSA.