Contraceptive Use among Young People in Uganda: Exploration of obstacles, enablers, and quality of services

Abstract: Background: Unsafe abortions, a life shortening condition leading to untimely deaths of young women in low income countries, are a public health concern. The bio-social gap, which is the period between menarche and marriage has widened, thus the time young women/men need contraception has increased. High rates of teen pregnancy, unintended birth, unsafely induced abortions and associated mortality among young women, is attributed to low contraceptive use. Paradoxically, awareness about contraception is high. It is not understood why young people are not using contraceptives, hence this study. Aim: To explore and analyze obstacles and enablers to contraceptive use and quality of services provided to young people aged 15-24 in two districts in Uganda, in order to increase knowledge about why contraceptives are not used and identify areas for improvement. Methods: The studies were carried out among young people 15-24 years and health care providers at public, private not for profit (PNFP), and private for profit (PFP) contraceptive delivery points. Quantitative and qualitative approaches were used. Focus group discussions (FGDs) were used to explore young peoples’ views about obstacles and enabling factors to contraceptive use (study I). Semi-structured questionnaires were used to guide face-face interviews with health care providers to determine factors influencing contraceptive use and provision (Study II). Simulated client methodology was used to assess the quality of contraceptive services and clients experiences of contraceptive care (Study III and IV). Descriptive statistics (II, IV), inferential statistics (II, IV) and factor analysis (III) were performed. Qualitative data were analyzed using content analysis (I) and thematic analysis (IV). Results: Young men and women described multiple obstacles to contraceptive use, which were categorized as misconceptions and fears related to contraception, gender power relations, socio-cultural expectations and contradictions, short term planning, and health service barriers (I). Additionally, young people recounted several enabling factors that included female strategies to overcome obstacles, changing perceptions and attitude towards contraceptive use and smaller family size (I). Contraceptive use and provision to young people were constrained by sporadic contraceptive stocks, poor service organization, limited number of trained personnel, high costs, and unfriendly service. Most providers were not competent enough to provide long-acting methods. There were significant differences in providers’ self-rated competence by facility type. Private for-profit providers’ competence was limited for most contraceptives. Providers had misconceptions about contraceptives, they had negative attitudes towards the provision of contraceptives to young people, and they imposed non-evidence-based age restrictions and consent requirements. Thus, most providers were not prepared or were hesitant to give young people contraceptives. Short-acting methods were, however, considered acceptable for young married women and those with children (II). Means and categorized quality scores for all aspects of quality were low in both public and private facilities. The lowest quality scores were observed in PFP, and medium scores in PNFP facilities. The choice of contraceptive methods and interpersonal relations quality scores were slightly higher in public facilities. Needs assessments scores were highest in PNFP facilities. All facilities were classified as having low scores for appropriate constellation of services. Information given to users was suboptimal and providers promoted specific contraceptive methods. A minority of providers offered young people their preferred method of choice and a minority showed respect for privacy (III, IV). Both qualitative and quantitative results highlighted favorable reception, provider bias, and low client satisfaction. Two thirds of the providers choose a contraceptive method for the client. The clients reported satisfaction with contraceptive services in 29 percent of the consultations. Privacy was reported to be observed in 42 percent and clients felt respectfully treated in 50 percent of the consultations (IV). Conclusion: Our findings suggest changing perceptions and attitudes in favor of contraceptive use and smaller family size although obstacles still exist (I). Provider, client, and health system factors restricted contraceptive provision and use for young people (II). The quality of contraceptive services provided to young people was low (III). Young people were not able to exercise their rights to choose, obtain and use contraceptives when needed. Overall satisfaction with the services was low and client- provider interactions were often unfavorable (IV). Implications: Reducing obstacles and reinforcing enabling factors through education, culturally sensitive behavior change strategies have the potential to enhance contraceptives use. Alternative models of contraceptive service delivery to young people are needed. Contraceptive use prospects are dependent on provider behavior. Concurrent quality improvements and strengthening of health systems are needed.