Understanding barriers and facilitators of sexual and reproductive health services uptake among adolescent women and men in semi-rural areas in KwaZulu-Natal, South Africa: a secondary analysis.

Abstract

Adolescents in South Africa face persistent barriers to accessing sexual and reproductive health (SRH) services, particularly in semi-rural settings where structural limitations, social norms, and service design intersect. This study explored how adolescents in semi-rural KwaZulu-Natal experience and navigate SRH services, and how behavioural, interpersonal, and systemic factors shape their engagement with care. Guided by the COM-B behaviour change model and a healthcare decision framework, the study examined how capability, opportunity, and motivation influence adolescents’ health-seeking behaviours. A qualitative design was employed, incorporating semi-structured interviews and visual elicitation through participant drawings of preferred clinic environments. Thematic analysis identified interconnected barriers related to distance, waiting times, confidentiality concerns, and healthcare worker attitudes, alongside facilitators such as youth-friendly service days, mobile clinics, peer support, and emotionally safe interactions. Findings revealed that adolescents are not passive recipients of care but active agents who critically evaluate services, propose design improvements, and develop strategies to overcome access constraints. Structural inefficiencies were found to carry emotional consequences, often producing embarrassment, anxiety, and disengagement, while respectful communication and predictable service organisation strengthened trust and motivation to return. The study contributes to existing literature by demonstrating that adolescent SRH access is not solely a logistical issue, but a behavioural and relational phenomenon shaped by symbolic meanings of belonging, dignity, and legitimacy. Effective service delivery, therefore, requires attention not only to infrastructure but to emotional safety, youth participation, and organisational responsiveness. The findings support policy directions that institutionalise adolescent voice in governance, expand youth-friendly service models, and integrate behavioural insights into health system design. Strengthening adolescent-responsive SRH services is essential for advancing equity, autonomy, and sustained engagement in South Africa and comparable contexts.