Study design

We followed the Joanna Briggs Institute (JBI) guidelines [12] to conduct a scoping review of published indexed literature and published theses. We followed the PRISMA-ScR guidelines to report the results of this scoping review (S1 Checklist PRISMA-ScR Checklist) [12]. The JBI guidelines include the application of the PRISMA-ScR. The JBI guidelines offer flexibility in the data analysis process [12]. We reported the findings of the analysis as a narrative summary of the included articles.

Sources

To include all relevant literature on this topic, we searched five relevant databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science) for indexed studies on June 14, 2023. We limited the grey literature to published theses to capture any recent literature that had not yet been published in scientific journals. Thesis searches were run in Theses Canada, and UBC Library archives for relevant literature. Further, we conducted citation searching by reviewing the reference lists of highly relevant studies to identify further studies.

Search strategy

Our review team included a PhD expert in qualitative methods and access to family planning services (SM), graduate students (VP, ZK), and a clinician-scientist (BO). The lead and senior author (SM, ZK) designed and provided oversight for the scoping review and worked closely with a subject librarian (VK) to develop and refine the search strategy (S2 File Search Strategy). We reviewed the search strategy of a recently published scoping review on abortion and contraception for incarcerated people in Canada and referred to their search terms for contraception as the initial basis for the scoping review search strategy [13]. Building on this, our search terms included a combination of ‘emigrants, immigrants, undocumented immigrants, refugees, transients, immigration, asylum seeker, displaced person, incomer, newcomer, migrant, and resettler’ and ‘adolescent, middle school, pubescent, juvenile, teen, youth, high school, young adult’ to define the population of interest. We used an unvalidated search filter developed by the University of Alberta to limit our search to studies that involved residents of Canada [14].

Inclusion criteria

Qualitative studies that described newcomer youth’s experiences of contraception care in Canada were eligible for this scoping review. Studies published before 2010 were not included, as we wished to focus on the current health system context. Available methods and attitudes toward contraception have changed over the last 13 years and we anticipated that studies published before 2010 will not provide an accurate depiction of the current experiences of youth accessing contraception care. Studies that applied qualitative methods such as focus groups, individual interviews, qualitative surveys, and arts-based methods met the inclusion criteria. We excluded conference proceedings, preprints, policy reports, and whitepapers from the grey literature search. We also excluded any study design that did not focus primarily on use of qualitative methods.

For the purposes of this scoping review, we defined newcomer youth as individuals who reside in Canada as temporary residents (for example, on a limited study permit visa), refugees, permanent residents as well and undocumented residents. Canada defines an ‘immigrant’ as a person who has been given the right to live permanently in Canada [15]. Both immigrants, as defined by Canada, as well as individuals who are not considered immigrants but self-identify as newcomers to Canada were eligible for participation in this research. In this review, youth refers to individuals aged 15–25 years. This upper limit of 25 is used frequently in Canada as the upper range for contraceptive subsidy programs for youth [16], contraception guidelines for youth [6,17], and surveys that analyze data on youth contraception access [18,19]. Therefore, studies that only involved children under 15 years or adults over 25 years old were excluded from this scoping review (S3 File Reasons for Excluding Studies).

The concept of ‘contraception access’ included intersecting factors such as knowledge of contraception, attitudes towards contraception, cultural and religious positioning, gender, transportation, insurance, and cost. Studies that explored SRH but did not mention contraception were excluded from the scoping review. Only studies conducted in English were included. See Table 1 for inclusion and exclusion criteria.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Inclusion and exclusion criteria for the scoping review.

https://doi.org/10.1371/journal.pone.0327997.t001

Screening, study selection and data charting

After two co-authors (BO, ZK) conducted the searches, all identified citations were included in Covidence, a web-based software developed by the Cochrane group to streamline evidence synthesis reviews [20]. We used Covidence to manage independent title/abstract screening, full text screening, data extraction, and risk of bias assessment, after which we used Excel spreadsheets to manage data extraction, analysis, and synthesis. Two co-authors (BO, VP) independently screened the literature. They met to discuss any discrepancies in the screening process. A third reviewer (ZK) met to resolve any conflicts that arose during this process. Two co-authors (BO, VP) conducted data extraction for included studies. After which, two authors (ZK, BO) conducted qualitative analysis, synthesis, and interpretation. The senior author (SM) provided feedback and guidance throughout the research process.

We adapted relevant headings for our data charting table from the JBI guidelines and a scoping review on adolescent health [12,21]. The data charting table consisted of the following headings: study title, authors, study objectives, methods, context or setting, participant characteristics, data analysis, and authors’ conclusions (S4 Data Charting Table). Data extraction of the included studies was completed by one team member (VP), while a second member (BO) reviewed the extractions, consistent with the JBI scoping review guidelines.

Analysis and synthesis

Finally, the review team (ZK, BO, SM) conducted a descriptive qualitative synthesis of the included studies. We re-read the included studies and data charts to summarize the qualitative methods, characteristics of participants, and descriptions of youth engagement in the research process. We summarized and synthesized study results related to contraception care. To ensure that we were accurately including all relevant data related to contraception access, we thoroughly reviewed each article and took note of instances where the author or a participant’s quote explicitly mentioned ‘contraception’, ‘birth control’, ‘condoms,’ or another method of contraception.

Data collection approaches

Boafo-Arthur (2013) conducted individual interviews to explore perspectives about sexuality among Ghanaian youth living in Canada [22]. In this thesis, the author considers the physical and social settings, and parental or caregiver attitudes with an ethnographic lens and explores how these factors influence Ghanaian youth’s perspectives about sexuality [22].

Ashdown et al. (2015) evaluated an SRH education intervention by conducting eight focus groups with youth [23]. The authors delivered a workshop that consisted of popular teaching strategies. This was followed by a focused group discussion to explore youths’ perception of commonly used methods to teach SRH, such as games, lectures, and hands-on demonstrations [23]. The authors used an inductive analysis framework to identify themes emerging from the focus groups [23].

Taylor et al. (2022) also developed and evaluated an SRH education intervention – a theatre-based sex education workshop [24]. Immigrant youth were recruited and trained as peer educators in this interactive workshop [24]. The authors used mixed methods including surveys, focus groups, peer interviews, and scene creation (peers role-playing and creating scenes related to the topic) to elicit qualitative data that evaluated the workshop [24]. The authors used thematic analysis to generate key themes from the data [24].

In the first of Meherali et al.’s two studies (2021), authors explored South-Asian immigrant adolescents’ experiences with access to SRH services in Alberta, Canada [25]. A doctoral student who led the study conducted four in-person focus groups and two virtual focus groups on the videoconferencing platform, Zoom [25]. Following the data collection, the authors applied thematic analysis to the study data [25].

Meherali et al. (2022) conducted another qualitative inquiry to better understand the SRH needs of immigrant adolescents in Canada [26]. In this study, the authors conducted twenty 45-minute individual interviews on the videoconferencing platform Google Meet, again analyzed through the lens of inductive thematic analysis [26].

Participant characteristics

Boafo-Arthur (2013) interviewed 15 Ghanaian youth, who were students at Brock University (Niagara, Ontario), and had been living in Canada for a period of 1–13 years [22]. Five participants were female, and 10 participants were male. Participants were 18–27 years old [22].

The Ashdown et al. (2015) study had 80 youth participants, aged 15 and 19 years [23]. Participating youths were newcomers and street-involved. However, the authors did not collect demographic information on the participating newcomer youth [23]. The authors also did not report the total number of newcomer youth participants in the study [23]. The authors defined newcomer youth as ‘young people who are recent immigrants and/or refugees to Canada’, however, they did not provide a definition of ‘street-involved’ youth [23]. The youth who participated in this study lived in a Canadian city. The name of the city was not disclosed in the study [23].

The study Taylor et al., (2022) conducted included 19 participants, with 10 participants who were female-identified and 9 who were male-identified [24]. Eighteen participants identified as a person of colour and over two-thirds of the participants were first-generation immigrants [24].

The focus groups conducted by Meherali et al. (2021) to explore the barriers and facilitators of SRH information among South-Asian immigrant adolescents, involved 42 immigrant adolescents aged 14–20 years [25]. Among them, 36 participants were female, and 21 participants were university students. Thirty-one participants lived in Edmonton, Alberta, with their parents [25].

Twenty-one adolescent immigrant youth participated in the study conducted by Meherali et al. (2022) [26]. The ages of the participants ranged from 14 to 19, with the majority (n = 18) participants being 18–19 years old. Only one of the participants was male [26]. The authors provided a detailed breakdown of the demographic characteristics of participants, including their birth countries and the languages they spoke [26]. Six participants were from India, two participants were from the Philippines and two participants were from Bangladesh [26]. One immigrant adolescent was from each of these countries China, Bahrain, Nigeria, Nepal, Venezuela, Colombia, Saudi Arabia, Malaysia, Kuwait, Ireland, and Kazakhstan [26]. Thirteen participants lived in Canada for over ten years at the time of participation [26].

Youth involvement in research

Two of the five studies included in this review created opportunities for meaningful youth involvement in the research process [24,26].

Ashdown et al. (2015) did not report the involvement of youth in the research process [23]. However, the authors described the involvement of youth-serving organizations, which helped the researchers reach immigrants and refugees from low-income countries [23]. Similarly, the studies conducted by Boafo-Arthur (2013) and Meherali et al. (2021) also did not report newcomer youth engagement in the research process [22,25].

Taylor et al., (2022) utilized a participatory action research approach, characterized by the explicit goal of empowering participants through the research as co-creators of the knowledge [24]. The authors took steps to mitigate barriers to youth participation in the research process and met with them regularly to ensure that youth remained active research partners [24]. In addition, the authors consulted youth partners to ensure that the project met the needs of the community where it took place [24].

In Meherali et al. (2022), the qualitative study conducted with youth participants aged 14–19 involved an adolescent advisory group consisting of immigrant adolescents, who reviewed and provided feedback on the interview guides [26]. One member from the adolescent advisory group also participated in seven of the 21 interviews that were conducted for this study, to observe and provide feedback on the interview process [26]. The adolescent advisory group met once a month with members of the research team, where they shared their insights on the research process [26].

Contraception access

Boafo-Arthur (2013) reported that Ghanaian youth living in Canada varied in their awareness and knowledge of contraception care [22]. One participant shared that although Ghanaian youth are aware of their contraception options, Ghanaian cultural influences intersect with their ability to obtain contraceptives. This participant [22] shared,

‘I think they [youth] are aware. I was aware as early as when I was in my early teens. I knew of condoms, though it’s not that I was using them but I knew of condoms and all those things. But, I think that people just don’t seem to like using them, because even if you are a youth and you go into a pharmacy to go and buy condoms, or even to a mall to go and buy condoms people are going to look at you in some weird way. If you meet an elderly person, you will be shocked that the elderly person might not even sell it to you.’

Participants in this study agreed that compared to Ghana, it is easier for them to access and learn about contraception in Canada [22]. One participant’s experience illustrates that the ease of contraception access in Canada is related to less stigma about sexual activity [22]:

‘A Ghanaian will go to the pharmacy shop to buy condoms and get there and there are people there minding their own business and you can’t even tell the person you are buying the condom. Why? Because they think you’re gonna have sex. When I came here the first month, I went to a convenience shop to buy something, and this guy just came in a loud voice, “I want the blue Trojan”, in front of everybody. Like he said it so loudly, “I am buying a condom”. You can never see anyone doing that in Ghana. That’s one huge difference. The awareness is there, but the perception of someone going to buy a condom, you are already condemned like you are a “whore”, you are a “player”, you like sex, you are “spoilt”.’

This attitude was reflected by another participant, who shared they had limited knowledge of contraception methods when they arrived in Canada, but have had opportunity to learn more about options since their relocation [22]. To that end, another participant shared,

‘In Ghana everyone just thinks of condom, condom use. It wasn’t until I got here that I learnt really about contraception and the after-morning pill that they do here. So I don’t think that there is enough awareness.’

In the evaluation of an SRH education workshop conducted by Ashdown et al. (2015), newcomer youth shared that language was an important factor in SRH education, and suggested ways to make it easier for participants who speak English as a second language. Their suggestions included practical steps, such as speaking slowly and allowing time for participants to comprehend the educational content. Youth participants further elaborated that the language used to communicate topics related to SRH had cultural implications beyond comprehension [23]. For example, some newcomer participants shared that words like penis, oral, and sex are not widely used in their first language, and expressed feeling more comfortable discussing these terms and related topics in English [23].

Most of the newcomer participants agreed that while SRH workshop facilitators do not have to be of the same cultural background as them, they should be familiar with the cultural backgrounds of the workshop participants [23]. In this study, Ashdown et al. (2015) also reported that newcomer participants found it challenging to reconcile what they had learned about SRH and contraception in their home countries, and what they learned in Canada [23], particularly involving abstinence education:

‘ABC: Abstinence, be faithful and the last, if you must, is use condoms. And here [in Canada], it changes so, condoms first and then the others.’

Continuing with a focus on education, Meherali et al.’s (2021) focus group investigation of the SRH information and service access barriers faced by South Asian immigrant adolescents aged 14–20 years identified that immigrant adolescents had mixed experiences with SRH education in school [25]. Contraception care was discussed in the context of school-based education, where eighteen participants shared that they received SRH education in school and learned about contraception care through school-based SRH education in Canada or their country of birth [25]. One participant expressed,

‘As SA [South-Asian] girl I am not comfortable talking with my mom about SRH... so school classes really helped me to understand male and female reproductive anatomy, fertilization, pregnancy, contraception etc.’

In contrast, twelve participants shared that they were not satisfied with the education that they received in school. One newcomer youth shared that they did not receive information about how to access SRH services [25],

‘In sexual health education classes, we mainly talked about periods, wet dreams, and briefly about pregnancy, STIs etc. I was never told about where to get tested for an STI, from where we can get emergency contraception, or learned where to get free condoms or contraception or where to access birth control…nothing was talked about in-depth.’

In Taylor et al.’s evaluation of a theatre-based sex education workshop (2022), the authors posit that newcomer youth may lack confidence and knowledge of contraception, hindering their ability to communicate about contraception with their partners [24]. The authors described this theme as ‘protection self-efficacy’, which refers to ‘one’s ability to effectively access, communicate about and ultimately use contraception with sexual partners’ [24]. According to the authors, most participants identified ‘safer sex’ to be one of the key learning from their participation in the workshop intervention [24]. In this study, newcomer youth participants also attested that interactions with peers of a different gender helped build their confidence in communicating about contraception [24]. One newcomer participant shared that their confidence in communicating with her partner about contraception improved following her participation in the workshop [24]:

‘I was a really shy person, like before the programme, right? But now I feel I’m okay with talking to guys about sex... I don’t think I would be shy... I’ll tell a guy things like when to use a condom. I’d be like, ‘Bro, no, you should use a condom. Like you have to.’ See? We’re learning.’

The same participant further elaborated that she intended to discuss their use of oral contraceptive pills (birth control pills) with her partner,

‘I have seen changes in myself, and I was actually planning to get on the birth control pill... My boyfriend and I have talked about it, and we think it’s a good idea.’

Although contraception made up a small section of the SRH findings reported in this study, it highlights an important aspect of the newcomer youth’s ability to communicate with partners, which can improve through new knowledge about contraception and SRH [24].

In the interview study conducted by Meherali et al. (2022), the authors described the structural barriers that immigrant adolescents aged 14–19 years old and living in Alberta, Canada faced when accessing SRH care [26]. This study focussed on the challenges that immigrant adolescents faced when accessing all forms of SRH services, including contraception care [26]. The authors draw connections between access barriers and the sociocultural context of immigrant youth families. Specifically, they highlight how parents’ attitudes toward SRH services influence newcomer youths’ abilities to access birth control [26].

This study also brings attention to the role of peers as a source of information about contraception [26]. Immigrant adolescent participants cited friends and peers as the second most popular source of information for SRH after the internet and media [26]. For example, one newcomer participant shared that,

‘I had a couple of friends that were on birth control, so I asked them about it, and they gave me the pros and cons of it, so that’s kind of what helped make my decision. I’d probably say my friends.’

Lack of focus on contraception access experiences

It is important to note that the qualitative studies included in this scoping review focused on broader SRH experiences, rather than contraception care. While there may be similarities between newcomer youth’s experiences of accessing SRH services and contraception care, comprehensive evidence that highlights the nuances of contraception access for newcomer youth remains scarce. The results of this review identified a knowledge gap in our understanding of contraception access for newcomer youth. Future studies should focus on examining the needs of newcomer youth pertaining to contraception specifically.

Lack of involvement of newcomer youth in the research process

Only two out of five studies included in this review describe youth engagement in the research process [24,26]. Taylor et al.’s (2022) participatory research action study design allowed youth to become ‘co-creators’ of the research evidence [24]. In Meherali et al. (2022), the authors invited immigrant adolescents to provide feedback on the interview guides and the interview process by creating an adolescent advisory group for the research. There is strong evidence to suggest that involving youth as research partners leads to the production of richer data and greater access to youth participants [29]. For instance, Wilkinson and colleagues demonstrated the success of engaging with youth aged 15–17 years in the co-development of a contraception navigator program for youth living in Indiana, USA [30]. Similarly, another qualitative study which involved Zambian youth (15–24 years) in a participatory research process to investigate their SRH needs provided further evidence to support the importance of youth engagement in the research [31]. Given this evidence, future studies that aim to explore newcomer contraception experiences should consider engaging newcomer youth in the research process to elicit rich data.

Further exploration of the role of peers in contraception access

In their respective studies, Taylor et al. (2022) and Meherali et al. (2022) demonstrate the role of peers in empowering newcomer youth to engage in discussions about contraception and sharing information about contraceptive methods [24,26]. This is consistent with global literature on the impact of peer-led SRH education for youth [32,33]. However, considering that the nature of peer relationships may vary between first-generation newcomer youth and Canadian-born youth, further investigation of the role of peers in influencing contraception choices is warranted. For instance, newcomer youth may encounter contradictory perspectives and discourse on contraception between peers in their birth country and Canada, as highlighted in studies included here [22,23]. As a result, it is crucial to understand where and how peers influence newcomer youth’s attitudes and awareness of contraception. This knowledge is essential to the development of solutions that are effective in supporting youth’s abilities to access contraception care.

One of the limitations of this review is that it does not incorporate all potential grey literature on this topic. The inclusion of grey literature can provide additional context, and practical insights from diverse perspectives such as government, and non-profits and capture ongoing studies on this topic. The search strategy designed to retrieve published studies from the databases could be further strengthened by including additional keywords to include all terms for different methods of contraception available in Canada. We did not conduct a critical appraisal of the studies included in this review. Although critical appraisals are not required for scoping reviews, including a critical appraisal of the studies could potentially improve the rigour and reliability of the data. Our scoping review excluded studies published before 2010. As a result, our scoping review does not capture how newcomer youth’s attitudes toward contraception have changed over the decade.

This scoping review describes the current evidence on newcomer youth’s experiences of accessing contraception and identifies key gaps in research. Lack of research that focuses on contraception experiences specifically, and limited involvement of youth in the research process, restrict our understanding of newcomer youth’s experiences of contraception access. Further research is needed to gain a deeper understanding of how cultural, religious, and parental attitudes toward contraception care intersect and influence newcomer youth’s access. Conducting research that focuses on youth contraception experiences and involves youth in the research process can generate further evidence and support the nuanced understanding of these issues.

In this scoping review, we have highlighted the role of peers in making contraception care accessible to newcomer youth [24,26]. There is an opportunity to further explore the role of peers beyond making youth aware of a contraception method, which could provide essential insights into the factors that allow youth to make decisions about contraception. Similarly, examining the various factors that determine ‘access’, such as the interplay between cost, insurance policies, transportation, geographical location of the participants, social and environmental factors and newcomer youth’s ability to access contraception care can provide a holistic understanding of how newcomer youth navigate contraception care [34]. Addressing these research gaps can help policymakers, educators, and healthcare providers develop programs, design policies and generate knowledge translation tools that are grounded in newcomer youth’s needs.

Canada is home to over 8.3 million landed immigrants [10]. As Canada welcomes more immigrants, this percentage is expected to increase and represent 29% to 34% of the Canadian population by 2041. According to Statistics Canada, youth make up 10.9% of the recent immigrant population in Canada [10]. Given that Canada is experiencing a steady growth in the immigrant youth population, this study highlights that it is pertinent that contraception care, which is an essential component of reproductive autonomy, is delivered in a manner that is acceptable and accessible by newcomer youth.