Participatory Action Research for Adolescent Sexual and Reproductive Health: A Scoping Review

Introduction: Youth-friendly sexual and reproductive health (SRH) interventions are essential for the health of adolescents (10–19 years). Co-designing is a participatory approach to research, allowing for collaboration with academic and non-academic stakeholders in intervention development. Participatory action research (PAR) involves stakeholders throughout the planning, action, observation, and reflection stages of research. Current knowledge indicates that co-producing SRH interventions with adolescents increases a feeling of ownership, setting the scene for intervention adoption in implementation settings. Objectives: This scoping review aims to understand the extent of adolescents’ participation in PAR steps for co-designed SRH interventions, including the barriers and facilitators in co-designing of SRH intervention, as well as its effectiveness on adolescents’ SRH outcomes. Methods: Database searching of PubMed, Medline, Embase, CINAHL, Scopus, Web of Science, Google Scholar, and organisational websites was performed, identifying 439 studies. Results: Upon screening, 30 studies (published between 2006–2021) met the inclusion criteria. The synthesis identified that adolescents were involved in the planning and action stages of the interventions, but not in the observation and reflection stages. Although the review identified the barriers and facilitators for co-designing SRF interventions, none of the included studies reported on the effectiveness of co-designing SRH interventions with adolescents; therefore, meta-analysis was not performed. Conclusions: While no specific outcome of the interventions was reported, all papers agreed that adolescent co-designing in ASRH interventions should occur at all stages to increase understanding of local perceptions and develop a successful intervention.


Introduction
The period of the maturation and development of adolescents into adulthood is an important phase of one's life that is often accompanied by heightened sexual attention, thought, and experimentation. The chance of contracting sexually transmitted infections (STIs), unintended pregnancies, or early childbearing increases with ill-informed early sexual experimentation [1]. Adolescents across the globe face sexual and reproductive health (SRH) complications, due to a lack of informative services, barriers to such services, social stigmas, laws, and policies [1]. The adolescent period involves significant development; thus, it can be determinative of SRH risks in later life. Consequently, adolescence is an optimal stage for targeted SRH interventions [2,3]. Providing suitable adolescent sexual and reproductive health (ASRH) interventions at the appropriate time and setting makes it possible to improve these statistics in the future.

Methodology
The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) 2018 guidelines [11] to complete the review (Supplementary Table S1).
The review included all experimental, observational, and qualitative studies, based anywhere globally, that involved adolescent participants aged 10-19 years. Studies that included youth aged up to 24 years were included, as long as the data, relating to the age group of interest, was included. The review focused on studies that involved codesigning ASRH interventions and reported PAR process (Figure 1), barriers, facilitators, and effectiveness of co-designed interventions on improved SRH outcomes. The review was gender-neutral and we avoided gender specific terminologies to avoid stereotyping, as it was interested in specific role of adolescents (regardless of their sex and gender roles) in co-designing interventions for SRH. The literature search was conducted on the following electronic databases: PubMed, Medline, Embase, CINAHL, Scopus, and Web of Science, as well as grey literature on Google Scholar and organizational websites. These databases were searched using a combination of natural language vocabulary and controlled terms (subject headings) wherever they were available. Natural language terms were derived from three main concepts: (1) sexual and reproductive health, (2) co-designing of interventions, and (3) adolescents. Publication date, language, and study type restrictions were not applied to increase search sensitivity. Other search methods were employed to retrieve additional evidence. The following search strategy was used to search the databases: "((Sexual) AND (reproductive) AND (health)) AND (adolescent* OR young OR teen OR teenage) AND (co-design OR codesign OR "community-based participatory research: OR "community-based participatory research" OR "consumer participation" OR "action research" OR "participatory design" OR co-production)".
All primary research studies from the databases were uploaded on Covidence, a webbased tool that helps to identify studies and involves data-extraction processes [12]. Two reviewers (BA and EN) independently screened all potential articles. In case of disagreement, both reviewers read the paper and discussed it with the senior reviewer (ZL) until they reached a consensus. The reviewers (BA and EN) independently screened all title/abstracts and eligible full-text articles and included papers in this review that satisfied the inclusion criteria.
We extracted relevant data from each study, including the year, study design, setting, target population, sample size, and co-designed activity for SRH intervention, and the results were measured and reported (see Table 1). Two reviewers (BA and EN) extracted data, and the senior reviewer (ZL) resolved the consensus. The literature search was conducted on the following electronic databases: PubMed, Medline, Embase, CINAHL, Scopus, and Web of Science, as well as grey literature on Google Scholar and organizational websites. These databases were searched using a combination of natural language vocabulary and controlled terms (subject headings) wherever they were available. Natural language terms were derived from three main concepts: (1) sexual and reproductive health, (2) co-designing of interventions, and (3) adolescents. Publication date, language, and study type restrictions were not applied to increase search sensitivity. Other search methods were employed to retrieve additional evidence. The following search strategy was used to search the databases: "((Sexual) AND (reproductive) AND (health)) AND (adolescent* OR young OR teen OR teenage) AND (co-design OR codesign OR "community-based participatory research: OR "community-based participatory research" OR "consumer participation" OR "action research" OR "participatory design" OR co-production)".

Results
All primary research studies from the databases were uploaded on Covidence, a web-based tool that helps to identify studies and involves data-extraction processes [12]. Two reviewers (BA and EN) independently screened all potential articles. In case of disagreement, both reviewers read the paper and discussed it with the senior reviewer (ZL) until they reached a consensus. The reviewers (BA and EN) independently screened all title/abstracts and eligible full-text articles and included papers in this review that satisfied the inclusion criteria.
We extracted relevant data from each study, including the year, study design, setting, target population, sample size, and co-designed activity for SRH intervention, and the results were measured and reported (see Table 1). Two reviewers (BA and EN) extracted data, and the senior reviewer (ZL) resolved the consensus.
Systematic and collaborative process ADVISORY GROUPS Collected primary data from 12 focus group discussions (6 in each country), eight with 55 adolescents and four with 22 adult participants.
to consult on how best to: (a) engage with the broader community for a successful project; (b) address culturally-sensitive issues; and (c) adapt, as needed, the educational pedagogies for local contexts.
-Indicate what changes need to be made to the original intervention informing adaptation, implementation, and evaluation plans.
No duration stated.
Cense 2020 [28] Dutch high school The Netherlands
Short semi-structured interviews to explore the range of issues connected to how pupils experienced sexuality education at school. Focus group discussions to explore these issues. Photovoice sessions used to create a more open space for pupils to reflect on how sexuality education could be. Condom-mapping workshops were held, and 11 'perfect' condom maps were generated. Groups of young people ranged from two to five people per map. Participants sat around a large paper outline of a condom.
Participants were asked to imagine their 'perfect' condom and to illustrate their ideas on the condom map, using both written and visual elements. • Through a series of workshops, youth brainstormed ideas for intervention content and design and developed rapid prototypes alongside the design team. Youth then reviewed ideas and provided feedback on multiple design and content iterations.
Participants in the intervention group are asked to complete a survey on the last day, after all intervention activities have been completed. Native community leaders and project consultants NTV research team included two faculty, a project coordinator from the University of Minnesota, and seven community consultants The project coordinator and community consultants (four adults; three youth, 18 -21 years).
Group discussion and questionnaires that took about 2 h. Focus group discussions co-led by an adult and youth native project consultant of the same gender as the participants in community-based organizations. The adult facilitator guided the focus group discussion using an interview guide containing core and probe questions. The youth facilitator captured participant ideas on a poster-sized flip chart and asked clarifying questions. Four 90 min consultations with YWG, 5 to 10 participants, with one researcher. YWG members shared their current understandings of preconception health, experiences of preconception care and how they currently obtain related health information. YWG members identified components of preconception health identified in q1 they would like to know more about and which components they felt were most important.
YWG members asked what they believe are the strengths and weaknesses of current resources, what were the most useful sources of information and what resource features or functions would best suit their needs. Preferences for graphic design and illustrations were also discussed. Six community consultations in the three study sites, with two meetings at each site with the following structure: one meeting with 13-17-year-old females and males and an adult adviser; and one meeting with 18-24-year-old females and males and an adult adviser. Development of short message services-no adolescent involvement. A total of 12 focus groups to validate SMS content each group of participants evaluated 36-37 SMS (146 SMS in total), each adolescent received a form to rate each SMS, ranging from very bad (1 point) to very good (4 points). • The focus groups were designed to determine health issues of concern for teens, their HIV and STI prevention knowledge, attitudes regarding HIV and STIs, their HIV and STI prevention sources of information, what they thought teens should learn during the intervention, and preferred characteristics related to intervention delivery.
Based on the information from the focus groups and the expert review panel, modifications were made to include more interactive activities. First, the youth selected the photographs that they deemed most pertinent to the discussion. Then they contextualized the photographs through their discussions. Finally, the youth codified their ideas through the pile sorting activity, which allowed them to identify themes and rank these in terms of priorities. They then used a systematic action planning process, described in Results section, to develop an action plan for each prioritized theme. Youth also had to identify the target for their solution, specifically which stakeholders in the community will help them carry out the plan. Designing the content and activity of the program. In the photovoice project, the model provided a way for the participants to think about their project in terms of its potential to empower them, as individuals, to help them develop and sustain healthy relationships, and, in turn, to advocate for themselves in their communities, institutions, and even in society at large. Aided in analysis of each co-researchers photovoice stories. Gaming experts with graduate and undergraduate degrees programmed the game with assistance from graphic artists, script writers, and audio/visual specialists.
Initial design and features of the game were driven by four meetings with the youth advisory board, where the initial game prototype-an initial version of the game-was developed and refined based on feedback obtained after each meeting. The advisory board then played the prototype for at least an hour and provided feedback on content, artwork, and design, minigames, dialogue, and entertainment value. All participants tested the game prototype and completed the system usability scale (SUS). Possible scores range from 0 (not usable) to 100 (perfectly usable). Focus groups with participants to guide additional development, to the game.  • 10 focus group discussions (FGDs), 11 in-depth interviews (IDIs) and observations.
within FGDs and IDIs were participatory activities, including community mapping, concept mapping and ranking. Data were generated through two purposive discussions with the participants. Discussions with the participants, led by a young researcher from their community rather than by (researchers), to encourage openness and honesty. The peer educator participants also decided to gather data from other youth in the school by means of short open-ended questionnaires. Individual interviews were taped and transcribed verbatim, and the peer educators synthesised the data they gathered by means of the questionnaires into narratives.

Twenty youth leaders 84 interviewees, 16-22 years not mentioned
Conducted four one-on-one interviews with their Chicago peers for a total of 80 individual interviews. Youth leaders created and disseminated surveys of their personal networks, including schools and colleges, and ICAH disseminated to national networks, including partnering organizations, movement building organizations, and school systems across the country that ICAH works with (convenience sample). Youth leaders participated in 1 in person focus group, facilitated by the youth education coordinator, which focused on connecting the online comfort-assessment survey to positive sexual decision-making among youths.
Participatory action research (PAR) framework: We used the PAR framework to assess the studies and synthesize the data. The adolescents were involved in the planning and action stages of the implementation, through various co-designing ways. Some used one method and others used a combination of co-designed workshops, focus group discussions, semi-structured interviews, in-depth interviews, photovoice sessions, and youth advisory committees or youth working groups/youth club meetings. The PAR framework for codesigning was used for preparing intervention programs for abortion [15], sex education material [16,21,23,27,28,31,32,41], contraception [17,40], risky sexual behaviour leading to STI/HIV [14,18,20,22,24,25,29,33,[37][38][39], adolescent pregnancy [30,34,35], preconception health [5], and peer education program [19,26,36]. Each of the included studies was assessed to understand the stages of PAR incorporated in co-designing SRH interventions for adolescents.
Planning: Studies have reported several different ways of involving adolescents in the planning phase. A study reported that the youth leadership council involved preparing and submitting the proposal to fund the research, identifying the target population, developing the study design, and disseminating the study findings [29]. Another study, through a series of workshops, involved youth in brainstorming ideas for intervention content and design and developed rapid prototypes alongside the design team [13]. Adolescents were also utilised in developing SRH education and HIV/AIDS prevention curriculum [41] and provided insight into what they would like to gain from the intervention [19,24,38].
Action: Action involves adolescents co-designing the pilot testing and actual implementation. The studies involved adolescents in one-on-one semi-structured interviews to gain an in-depth understanding of the adolescent experience and care trajectories [15] and explore the range of issues connected to how pupils experienced sexuality education at school [28]. Additionally, they built advisory groups to consult on how best to engage with the broader community for a successful project, address culturally-sensitive issues, and adapt the intervention [13,30]. They also shared their knowledge on HIV and STI prevention, attitudes regarding HIV and STIs, and self-stigma. Adolescents feel fear, as well as alone, and some are in denial about their status [19,33,38]. On the other hand, adolescents were involved in the implementation phase of a few studies, where they facilitated the condom-mapping workshops, prototype testing, and supplied feedback on improvements [22,24,25,[31][32][33][34]39,40].
Observation: Only one study reported involving the youth leadership council in disseminating the study findings [29].
Facilitators: Twenty-two studies identified facilitators to co-designing, including cultural adaptation [16,30,39], culturally relevant content [20,23], a reliable, professional, and friendly tone of researchers [31,36], and a safe atmosphere [24,28,32]. Furthermore, peer navigators were seen as facilitators of co-designing as adolescents were more comfortable sharing SRH issues, such as condom use, with their peers rather than adults. Additional facilitators identified include reliable content [31,32], adolescents feeling as though their involvement was effective in addressing critical problems [32], and a continuous feedback loop with community inputs [33]. Four studies found that using technological devices was useful to overcome the barriers of remoteness and poor transport and effective use of technologies in remote areas [34,35,40]. Further facilitators were identified as engaging youth as critical informants [5,18,19,25,26,37,41], and interventions that support school policy, values, standards, and behavioural expectations facilitated co-design partnerships [14,41].
Effectiveness of co-designing of SRH interventions: The studies did not report on the effectiveness of co-designing of SRH interventions with adolescents; therefore, metaanalysis was not performed.

Discussion
This review aimed to understand adolescents' participation in PAR for co-designed ASRH interventions. The studies included in this review collectively indicate the benefits of co-designing ASRH interventions and different ways adolescents can be involved. Following the PAR framework, adolescents were engaged in developing SRH interventions through the planning and action stages. During the planning aspects of the interventions, adolescents were involved in preparing and submitting the proposal [13,29]. This information was provided by adolescents' involvement in youth leadership groups and workshops, which aided the design team in the rapid development of the intervention [13,29].
The information and insight provided by the adolescents allow the primary research to gain an improved understanding of their current knowledge on SRH topics and what they want to gain from the intervention [19,24,38,41]. Throughout the action stages, adolescents were involved in trialing, collecting data, questioning fellow adolescents, and other pilot testing interventions. Adolescent-led, semi-structured, one-on-one interviews, group discussions, and advisory groups were used to explore a range of SRH issues and consult on how best to engage with the broader community for a successful project to address culturally-sensitive issues [13,28,30]. Through the implementation and troubleshooting of the interventions, adolescents were able to supply feedback and improvements to adapt to the intervention [24,25,[31][32][33][34]39,40]. Only one study planned on involving the adolescent in the observation stage, through a youth leadership council that was involved in disseminating the study findings, although this stage of the intervention had not yet occurred at the time of publication [29]. However, no studies involved or mentioned the future involvement of adolescents during the reflection stages.
Although the age groups, number of participants, and setting of the studies were identified, there was no difference in the extent to which adolescents were involved between the study characteristics. The only identified difference was that smaller participation groups allowed for slightly more detail in their explanations of their current knowledge on ASRH and what knowledge they wanted to gain [19,24,38,41]. Although these findings indicate that adolescents can be successfully involved in the planning and action stages of the PAR framework, the collective theme of the included studies concluded that with the development of a SRH intervention and a greater understanding of local perspectives, adolescents play a vital role in co-designing ASRH interventions.
Furthermore, this review identified many barriers and facilitators to co-designing ASRH interventions. Barriers stemming from cultural and social influences, judgment, and taboos were highlighted throughout the studies [16,20,23,30,39]. However, the physical barriers, relating to remote communities and poor transport, identified in some studies were directly identified by other studies and used technology to connect and overcome geographical and transportation limitations [18,19,24,[33][34][35]40]. An overarching facilitator of the studies was that the research was conducted in a friendly and professional manner, as well as to remind the adolescents that they are in a safe environment at all times [24,28,31,32,36]. This review provided a broad insight into the barriers and facilitators associated with co-designing ASRH intervention during the planning and action stages of the PAR framework, which can be used to inform future research.
Another objective of this review was to assess the effectiveness of co-designing on adolescents' SRH outcomes. However, as the identified studies did not report on the effectiveness of co-designing ASRH interventions, this objective could not be met.
To the best of our ability, we believe that this review is thorough, regarding adolescents' involvement in PAR for co-designed ASRH interventions. We believe we have included all possible published studies, concerning the topic, as we have conducted extensive literature searching on multiple databases and grey literature sites, as well as title searching of included studies. Potential biases were not identified, and no quality assessment was performed on these studies, as it was a scoping review. To identify potential bias, an investigation should occur to see if the author and/or primary researcher of each study have the potential of personal gain for the success of the intervention. No previous systematic reviews exist, concerning PAR for co-designed ASRH interventions; therefore, we could not determine whether there are any discrepancies within the findings and if they agree or disagree with previous reviews.

Conclusions
This review aimed to understand adolescents' participation in PAR for co-designed ASRH interventions, including the barriers and facilitators, and assess the effectiveness of co-designing on adolescents' SRH outcomes.
The collective theme of the included studies concluded that with the development of a SRH intervention, as well as a greater understanding of local perspectives, adolescents play a vital role in co-designing ASRH interventions.
As there is no current systematic review on this topic, it is suggested that the barriers and facilitators, verbalised by the adolescents, be accommodated in future research to improve the effectiveness of the interventions. Future studies should also involve adolescents in these interventions' observation and reflection aspects, in order to complete the PAR cycle. Furthermore, future systematic reviews should assess the outcomes of these designed interventions documented to assess their effectiveness.
Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/sexes3010015/s1, Table S1: PRISMA-SR Checklist.  Institutional Review Board Statement: Not applicable. This review did not require ethical clearance.

Informed Consent Statement: Not applicable.
Data Availability Statement: The corresponding author can be contacted for detailed data extraction sheets for all the included studies.