What we know and don’t know: a mapping review of available evidence, and evidence gaps, on adolescent sexual and reproductive health in Bangladesh

Figures & data

Table 1. Research gaps in adolescent sexual and reproductive health in developing regions

Research gaps	Focused area
Coverage gaps	Unmarried/never-married women in many countries (including Bangladesh) are excluded from fertility and health surveys or included but not asked questions related to sexual activity Adolescents younger than 15 are not typically included in national fertility and health surveys Adolescent boys receive insufficient attention in national fertility and health surveys Youth in vulnerable situations, such as refugees and youth living on the street, are not typically included in national fertility and health surveys
Under-reporting gaps	Sexual activity among adolescents may be underestimated because respondents may be reluctant to admit to having intercourse at young ages and outside marriage Induced abortion prevalence and the circumstances under which they are obtained: data are extremely limited, especially in countries with highly restrictive abortion laws
Substantive gaps	Human rights dimensions of ASRH are often undocumented, such as restricted access to ASRH education and services, child marriage, coerced sex or sexual abuse, and their impact on adolescents’ education and job prospects Health impacts of adolescent pregnancy and childbearing, particularly age differentials in maternal morbidity and mortality Long-term economic impacts of adolescent childbearing, separating the effects of age from those of poverty and low education Adolescents’ pregnancy and childbearing intentions, assume that most adolescent births, even those to very young adolescents, are intended Reasons for unmet need for contraception fail to provide adequate details to identify corrective interventions Other issues include sexuality education, sexual identity, sexual orientation, bulling and same-sex behaviours

Figure 1. Literature review flow diagram

Table 2. Information gaps on adolescent sexual reproductive health behaviours in Bangladesh

Research gaps	Focused area	Gap analysis with respect to the current literature
Coverage gaps	Unmarried/never-married women	Unmarried women and girls are primarily not included in national fertility and health surveys in Bangladesh, except for the Global School-based Health Survey. However, 10 articles sharing non-nationally representative data had information about unmarried girls. Only two covered sexual activity, one covered contraceptive use, and one covered desired fertility among these articles. There is also a lack of information on premarital sexual activity among unmarried adolescents.
	Adolescents younger than 15	Similar to unmarried women, adolescents younger than 15 are typically not represented in national fertility and health surveys, with the Global School-based Health Survey being the exception. In this review, seven papers, including one large survey and six small-scale studies, provided information on adolescents under age 15. These studies elicited rich information about younger adolescents’ awareness, sources of information, experiences, and attitudes in relation to SRH topics. However, significant gaps exist in information about behaviours and service needs for ethnic minorities, religious minorities, adolescents living with disabilities, and sexual and gender-diverse young adolescents. Though small-scale research has been conducted on some of these groups, we found a lack of diversity and intersectionality in the lens used in surveys.
	Adolescent boys	Eight papers included adolescent boys. Of these, one was the Global School-based Health Survey (the only national survey to include adolescent boys) which asked about sexual intercourse and condom use, and three were policy notes that briefly summarised data from a range of types of respondents, including adolescent boys. One nationwide study, which adopted mixed methods, was conducted to understand the SRH needs of male youth (15–24 years), such as puberty, social norms, sexuality, and masculinity. Other studies reported detailed information about adolescent boys’ perceptions on SRH. We found that gaps remain in representative data about adolescent boys’ SRH behaviours and effective ways to reach them with SRH information and services.
	Youth in vulnerable situations (marginalised, vulnerable groups, young males and females living with disabilities)	Seven articles included information on youth living in vulnerable situations, including youth living in streets, slums, and females living with disabilities. A national survey was also conducted on persons living with disabilities, including women with chronic maternal morbidities, which highlighted SRH service gaps.^Citation14 Therefore, targeted public health programmes on adolescents have been identified as major interventions for bridging the disability-related service gaps.^Citation15 Four studies focused on a range of youth who belong to marginalised groups, such as orphans, sex workers, slum dwellers, refugees, child brides, and young men living on the street who pay for sex. Apart from adolescents living in slums, significant gaps remain in obtaining SRH information from adolescents who are migrants, refugees, internally displaced, or HIV-positive persons who are mentioned only in one or two micro-studies. There was also no information about people who belong to lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) communities. To fill up these gaps, the Gender and Adolescence: Global Evidence research^Citation16 has been initiated in six low- and middle-income countries, including Bangladesh, to generate evidence on effective initiatives to support adolescents.^Citation17
Under-reporting gaps	Sexual activity	Only two studies that included unmarried adolescents measured the proportion of adolescents who had had sexual intercourse. However, neither reported whether intercourse happened in or outside of marriage. A third study examined practices of young men living on the street paying for sex, and two qualitative studies discussed concerns about, or evidence (e.g. reports from health workers about unmarried girls seeking abortions) of unmarried boys and girls having sexual relationships. One of these also reported that adolescent boys disclosed having seen sex workers and/or participating in rape. Despite these studies, there are extensive knowledge gaps regarding adolescents’ premarital sexual activity and experiences, for instance, related to sexual debut, relationships, online encounters, intrafamilial sexual abuse, masturbation, fantasies, fears, and coerced versus consensual interactions, including whether sexual debut among adolescent boys or girls occurred prior to marriage.
	Induced abortion	Four studies touched on the topic of induced abortion: adolescents’ awareness of it, whether induced abortions occur more frequently with unintended pregnancies and in the context of child marriage, and, more generally, their context and frequency among women 15–49. However, similar to the gaps noted across countries, information about the prevalence and circumstances under which abortions are obtained, particularly for unmarried girls, is extremely limited.
Substantive gaps	Human rights dimensions of ASRH (e.g. child marriage, coerced sex, sexual abuse)	A large number of studies (21) discussed contexts of human rights violations in relation to ASRH, including 4 national surveys. Topics covered included adolescents’ lack of awareness and sources of information about ASRH, restricted access to ASRH services, child marriage, sexual harassment, physical and emotional violence, limiting attitudes of teachers and healthcare providers toward information and services directed at adolescents, and transactional sex. While these topics could be classified as violations of human rights, the information itself was not framed from a human rights perspective (i.e. the conceptual framework was not about examining whether human rights were upheld or violated). Further, apart from declining trends in early marriage and childbearing, topics related to the enjoyment of ASRH rights – such as rights to non-discrimination, self-determination, love relationships, elopement (not all marriages are forced child marriages, but many are love affairs), peer groups, pleasure, desire, and changing norms, if any, amongst certain groups (i.e. single working adolescents), privacy and choice – were also not reflected.
	Health impacts of adolescent pregnancy and childbearing	Seven papers discussed the health impacts of adolescent pregnancy and childbirth, including two national surveys, though none of them analysed health impacts in depth or studied a cohort over time.
	Long-term economic impacts of adolescent childbearing	None of the studies looked at the long-term economic impacts of adolescent childbearing.
	Adolescents’ pregnancy and childbearing intentions	Twelve studies looked at adolescents’ pregnancy and childbearing intentions. While many discussed the large influence that mothers-in-law and husbands have on childbearing decision-making for married adolescents, none examined the reasons behind adolescents’ own desires to bear children, in particular at very young ages.
	Reasons for unmet need for contraception (with adequate details to inform interventions)	Three studies, including two national surveys, discussed reasons for the unmet need for contraception among adolescents. However, only one was reported with adequate detail to help shape interventions to reduce unmet needs.
	Sexuality education, sexually transmitted infections, sexual identity, sexual orientation and same-sex behaviours, and bullying	Four studies described issues related to sexually transmitted infections, three touched on sexual identity and same-sex behaviours, and two studies discussed sexuality education. Studies on sexuality education were not an explicit focus of this paper, and thus there is likely more published on sexuality education in Bangladesh than was gathered in this review. There is a dearth of published research on peer victimisation, such as the aggression of traditional bullying and cyberbullying among adolescents in the digital age. We have identified the lesser attention to and lack of acknowledgment of the limited qualitative research examining the lived realities of adolescents from diverse marginalised population groups – e.g. disabled, homeless, urban and rural poor, and people belongs to LGBTQI community.

Figure 2. Contraceptive method mix among married adolescent girls age 15–19 (N = 2006). Source: BDHS 2017/2018.

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