UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (15-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA BY: SUSAN BABIRYE KAYONGO.

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1 UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (5-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA BY: SUSAN BABIRYE KAYONGO MakSPH-CDC FELLOW FEBUARY 23

2 UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (5-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA BY: SUSAN BABIRYE KAYONGO B.MASS COMM.; MPHL MakSPH-CDC FELLOW MakSPH-CDC FELLOWSHIP PROGRAM FEBUARY 23

3 Table of Contents LIST OF TABLES AND FIGURES... iii DECLARATION... iv DEDICATION... v ACKNOWLEDGEMENTS... vi ACRONYMS AND ABBREVIATIONS...viii OPERATIONAL DEFINITION OF CONCEPTS... ix ABSTRACT.... INTRODUCTION AND BACKGROUND Introduction Background Statement of the Problem Significance of the Study LITERATURE REVIEW Background Information on Youths Sexuality and Contraception Sexual Behaviors of Youths in Sub-Saharan Africa Contraception among Youths in Uganda Factors Affecting Contraceptive Use among Young People Individual Factors Reproductive Health Service Factors Research Questions and Objectives Research Questions General Objective Specific Objectives Conceptual Framework METHODOLOGY Study Design Study Area and Population Study Area Sample Size Sampling Procedure... 2

4 3.2.5 Study Variables Data Collection Procedures Tools Data Management, Quality Control and Analysis Data Management Data Analysis Ethical Considerations RESULTS Introduction Demographic Characteristics of Respondents Socio-demographic Characteristics of Respondents Sexual and Reproductive Behaviors and Experiences of Respondents Use and Preferences of Contraceptives among Respondents Contraceptive Prevalence Modern Contraception Preferences of Respondents Contraceptive Use Behaviors and Practices among Respondents Source of Contraceptives at Community Level Factors that Influence Uptake of Modern Contraceptives among Respondents Logistic Regression Predicting the Likelihood of Modern Contraceptive Use Logistic Regression Predicting the Likelihood of Condom Use Logistic Regression Predicting the Likelihood of Use of Depo-Provera Young People s Perceptions towards Receiving Contraceptives from the Different Service Providers at Community Level Perceptions of Youths towards Contraceptive Uptake by Youths Perceptions of Youths towards Availability and Variability of Contraceptive Services Perceptions of Youths towards the Information Given to Clients Perceptions of Youths towards Provider s Technical Competences Perceptions of Youths towards Provider s Interpersonal Relations Perceptions of Youths towards the Availability of Mechanisms for Continuity of Contraceptive Use Perceptions of Youths towards Constellation of Services ii

5 4.6. Community level provider s perspectives on provision of contraceptives to youths Non Attitudinal Factors Attitude Related Factors DISCUSSION Introduction Discussion CONCLUSIONS AND RECOMMENDATIONS Conclusion Public Health Implications & Recommendations... 6 REFERENCES iii

6 LIST OF TABLES AND FIGURES TABLE : Socio-demographic characteristics of respondents....3 TABLE 2: Sexual and reproductive behaviors and experiences of respondents by contraceptive uptake TABLE 3: Age, sex, marital and schooling status of respondents by modern Contraception. 32 TABLE 4: Unadjusted and Adjusted Odds Ratios for the factors influencing modern contraception among respondents TABLE 5: Unadjusted and Adjusted Odds Ratios for the factors influencing use of Condoms among respondents...38 TABLE 5: Unadjusted and Adjusted Odds Ratios for the factors influencing use of Depo-Provera contraceptive among respondents FIGURE : Contraceptive method used by age groups and marital status of respondents 33 FIGURE 2: Source of Contraceptives at community level..35 FIGURE 4: Depo-Provera injections taken consecutively by injectable users 36 iii

7 DECLARATION I, Susan Babirye Kayongo do hereby declare that this research report entitled use and uptake of modern contraceptives among youths at community level in Busia district, Uganda has been prepared and submitted in fulfillment of the requirements of the MakSPH-CDC Fellowship Program and has not been submitted for any academic award. SIGN: DATE: LONG TERM FELLOW: BABIRYE SUSAN KAYONGO APPROVED BY: SIGN: DATE ACADEMIC MENTOR: DR. SUZANNE N KIWANUKA. DDS, MPH, PhD SIGN: DATE HOST MENTOR: DR. ANGELA AKOL. MB Ch B, MPH Uptake and use of modern contraceptives among youths (5-24) at community level in Busia district, Uganda. pages Babirye Susan Kayongo, 23 iv

8 DEDICATION This book is dedicated to the two men in my life; my dear husband Moses and our precious son baby Raees. v

9 ACKNOWLEDGEMENTS I would like to begin by expressing my appreciation first to the FHI36-Uganda team for the support given to me during my fellowship placement. Without their friendship, knowledge and expertise I would not have been able to successfully complete my fellowship placement. To the youths who comprised my study population in Busia district, I would like to thank you heartily for the open contribution in sharing your private experiences on sexuality and contraception. For my qualitative and quantitative research teams, thank you for enduring the hot sun and long working hours during data collection. In the same vein, I would like very much to thank the District Health Team of Busia and specifically the DHO (Dr. GB Oundo) for being very supportive particularly during proposal development and data collection. It is difficult to choose the right words in an adequate quantity with which to describe how grateful I am to my mentors both from FHI 36 and MakSPH-CDC fellowship program. Dr. Angela, right from the time we met, you took interest in seeing me grow professionally. Thank you for the continued guidance, support and opportunities given to me, that enabled me to continuously grow my technical skills. Dr. Suzanne, while you were my mentor, in many ways you were a trusted friend. You comforted me and paid attention to specific details that affected the context of my training and most of all you offered me profound advice. Your friendly approach to Mentorship was remarkable. I cannot forget my roving mentor Dr. Noerine Kaleeba, for continuously checking on me and for the inspirational talks that gave me a lot of courage to carry on. Special thanks go to the administration of MakSPH-CDC fellowship program, first for giving me this invaluable opportunity to participate in this excellent and informative program; and for your continued technical support and guidance during my fellowship. To Mr. Matovu and Dr. Rhoda, I must say I found your detailed and timely comments on my work extremely easy to understand. Thank you very much. I also thank MakSPH- CDC fellowship program, for funding this research project. vi

10 To my beloved family, I dedicate this report. Moses, my dear husband, you were so supportive right from the beginning of this fellowship program. You endured my absence and tight schedules patiently and this encouraged me to work harder. Your presence in my life will always be felt. Thank you for engaging our precious gift Raees every time I opened a laptop at home to complete the endless fellowship deliverables. To you our baby Raees, I know one day you ll be able to read this book. I want you to know that you re mummy s greatest source of inspiration and when you grow-up; I want you to be a go getter too. The sky should be your limit. I am equally indebted to my siblings who have continuous given me moral support. Thank you to you all. To my fellow fellows, thank you for being wonderful people. The togetherness you have automatically made me go through the fellowships obligations with a passion. Above all I give glory to the Almighty God who is my wisdom and strength, and for another opportunity to increase my knowledge to serve my generation. For God and my country vii

11 ACRONYMS AND ABBREVIATIONS CBD CBDI CDC CRTU FP H/C IDI MOH Community-Based Distribution Community-Based Distribution of Injectable contraception Center for Disease Control and Prevention Contraceptive and Reproductive Health Technologies Research and Utilization Family Planning Health Center In-depth Interviews Ministry of Health PROGRESS Program Research for Strengthening Services SC SRH VHT VHTM UNCST Save the Children Sexual Reproductive Health Village Health Team Village Health Team Member Uganda National Council for Science and Technology viii

12 OPERATIONAL DEFINITION OF CONCEPTS Contraception: The practice of utilizing methods intended to prevent or space future pregnancy. Contraceptive uptake: For this study will be reported picking or buying of contraceptives in the last one year. Contraceptive method choice: Contraceptive method which a youth report using at the time of the collection of data. Contraceptive Prevalence Rate: For this study refer to the proportion of youths (both males and females) who will report using or having used a modern contraceptive method in the last one year preceding the study. Contraceptive use: For this study will be reported actual utilization or intake of contraception in the last one year. Modern contraceptive methods: Short term modern contraceptive methods distributed by CBDs i.e. condoms, pills and injectables. Sexually active: For this study, will be reported sexual relationship in the last one year. Sexual relationship: An intimacy relationship involving sexual intercourse. Traditional contraceptive methods: These consist of periodic abstinence and withdrawal. Unmet need: Sexually active married or unmarried women that do not want to have a child in the next two years or ever and are not using a modern contraceptive method, yet they need to use this method. CBDs: Village Health Team Members (VHTMs) who are trained and offer contraceptives in the communities. CBDFP: Community Based Distribution of Family Planning Youth: A person between the ages of 5 and 24 ix

13 ABSTRACT BACKGROUND: Uptake of contraceptives among youths in Uganda is still low due to limited access to contraceptive services. Despite National plans and guidelines encouraging CBD approaches to increase FP access among underserved populations, there is hardly any studies on CBDFP that has focused on youths. The aim of this study was to assess the uptake of contraceptives and the factors which influence uptake among youths aged 5-24 years within the project area of CBDFP in Busia district, Uganda. METHODS: This was a descriptive cross sectional study conducted between May and August, 22. It consisted of a mix of qualitative and quantitative methods i.e. a community survey, four Focus Group Discussions (FGDs) with 48 sexually active youths and eight in-depth (IDIs) interviews with contraceptive providers. Quantitative data were analyzed using SPSS while qualitative data analyzed manually using a thematic framework approach. RESULTS: A total of 323 sexually active young people participated in the survey. Female respondents constituted the biggest proportion (62%) of the survey respondents where as 3% (43/323) of all the survey respondents were married and below 2 years. A big proportion (62%) of respondents reported using modern contraception and majority of the users (56%) sought contraceptives from government health facilities. Only 4% from CBDs. Condom was the most used method at 7.7%, followed by Depo-Provera at 3.8%. Sex and marital status were found to significantly influence condom use [sex: OR =2.74; 95% CI = ; marital status OR =2.27; 95% CI =.-4.65] whereas, age and marital status had a statistical significance with use of Depo-Provera [age: OR=.43, 95%CI=.2-.87; marital status: OR=.3, 95%CI=.6-.3, respectively]. Qualitative data showed gaps such as limited contraceptive options, inconsistent supply and, absence of counseling from drug shop operators. IDI s revealed that providers had misconceptions about contraceptives, negative attitudes towards the provision of contraceptives to young ones and unmarried young people. CONCLUSION: Majority of the sexually active youths used contraceptives and uptake of a given method was mainly influenced by age and marital status. Therefore, to improve contraceptive uptake among young people, age and marital status of targeted youths should be put into consideration and dispensing contraceptives should be accompanied by adequate information to facilitate continuity.

14 . INTRODUCTION AND BACKGROUND. Introduction Worldwide there over.8 billion young people and nearly 9 percent of whom live in developing countries []. The age-range 5 to 24 is a period when most people begin to actively explore their sexuality. Globally, most people become sexually active before their 2 th birthday [2] and in sub-saharan Africa, 75 percent of young women report having had sex by age 2 [3]. Research indicates that youths who begin early sexual activity are at high risk of having high-risk sex (having multiple partners, engaging in unprotected sexual activity, and experimenting sex with alcohol and other drugs), thereby increasing their risk for unintended pregnancy and sexually transmitted infections including HIV/Aids[4,5]. Among youths, rates of early and unplanned pregnancies, unsafe abortions, maternal deaths and injuries, and sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) are very high. One in every births and one in abortions worldwide and one in six births in developing countries is to women aged between 5-9 years. Each day half a million of young people are infected with a sexually transmitted disease [6]. Nearly 2 million young people are living with HIV/AIDS; and more than 7, young people become infected with HIV every day [7]. While about 6 million adolescent girls aged 5-9 give birth each year, accounting for more than per cent of all births worldwide.[8]. Young people s reproductive choices have an enormous impact on their health, schooling and employment prospects, as well as their overall transition to adulthood [9,]. Particularly, early childbearing has been linked to higher rates of maternal and child morbidity and mortality, truncated educational opportunities, and lower future family income, larger family sizes, which in turn may lead to greater population growth []. Research shows that use of contraceptive services is beneficial for women s health and important at meeting HIV prevention goals: it has been shown to be more cost effective to prevent the birth of HIV positive children through providing family planning to 2

15 women in the general population than increasing the provision of Nevirapine for HIVpositive mothers within antenatal care [2]. The literature suggests that, in general, sexually active unmarried adolescents are not seeking to become pregnant, and married adolescents may not wish to become pregnant at a young age or, if they have already had a child, wish to delay a second pregnancy [3]. Despite those facts, contraceptive prevalence rate in Sub Saharan Africa has generally remained low at only 2 percent and adolescent girls being the age group with the lowest contraceptive prevalence rate [4]. Worldwide, a number of service delivery approaches have been used to bring family planning services to underserved populations such as youths of developing countries. The most common family planning service delivery approaches applied comprise health facilities, health posts, health centres, hospitals, and community-based distribution (CBD), which includes commercial retail sales, door-to-door service delivery, and workplace distribution. A facility-based service delivery approach provides family planning services through public health centres and hospitals while the community-based approach uses workers who live in or visit communities to provide services that a woman would traditionally have had to travel to a clinic outside her community to obtain [5]. The major advantage of using facility-based FP service delivery is that it can provide medically complex methods, such as IUCDs, hormonal implants and sterilization. Whereas in areas that do not have any type of health facility nearby or where there barriers to accessing health facilities, family planning services may be made available through community-based distribution or CBD programmes..2 Background Uganda has the youngest age structure in the world; with 77 percent of its population under the age of 3 and about 2 percent aged 5-24 years [6]. In Uganda, young people typically become sexually active, marry, and bear children early in life. By 5 years of age, percent of adolescents have initiated sex and by 8 years 64 percent of young 3

16 people have had their first sexual encounter [3]. Young women in Uganda are particularly vulnerable to consequences of early pregnancy, unsafe abortion and unsafe sex. Uganda s reproductive health indicators continue to be poor, with a maternal mortality ratio of 435/, live births. With one of the highest total fertility rates in sub-saharan Africa, at 6.7 children per woman, teenage pregnancies constitute 25 percent of all pregnancies in Uganda [7]. Birth intervals remain short, and Ugandan women have more than three children by their late 2s [6]. Nearly half of the.4 million annual pregnancies occurring in Uganda are unwanted [8]. Unintended pregnancies have been linked to unsafe abortions that constitute nearly one third of maternal deaths among young people in Uganda [9]. Uganda has a liberal family planning policy that allows access to contraceptive services to every sexually active individual and couples irrespective of age [2], and in addition, contraceptives are free in public facilities and private facilities charge low fees as a commercial marketing strategy. However, despite all the above favorable factors a large proportion of sexually active Ugandan youths have never used contraceptives. Only - 2 percent of young people report ever using modern contraceptives apart from condoms [2] despite awareness of at least one contraceptive method being high at 98 percent [22]. The demand for contraceptives among Ugandan young people is 45 percent and 57 percent for age groups 5 9 and 2 24 respectively [23]. Studies have revealed that youths are neither well-received nor comfortable in mainstream family planning clinics, which are mostly government-owned maternal and child health/ family planning MCH/FP) facilities and thus the need for new approaches with proven strategies to keep contraceptives available in often challenging situations [24, 25]. Further still, more than 8 percent of the Ugandan population lives in rural areas where access to clinical family planning services is inadequate. For these reasons, community health programs remain an important mechanism for distributing contraceptives. In the Community Based Distribution (CBD) approach, CBDs usually village women or men are trained to educate their neighbors about family planning and to distribute certain contraceptives. 4

17 In Uganda, community-based family planning programs are many and varied, and have made a significant contribution to the success of national family planning efforts. Each program focuses on bringing appropriate family planning counseling and supplies out of the clinic and into the community. According to FHI, CBD of family planning has been practiced for the last 26 years in Uganda and CBD activities have been implemented in 66 (82.5 percent) of the 8 districts in Uganda at some point in time [26]. Several organizations, including the Ministry of Health (MOH) and about Non- Governmental Organizations (NGOs), have or still provide family planning services through CBD programs in Uganda. FHI36, an international organization with an office in Uganda, runs one of the largest CBD program, established in 26. To date, FHI36 has supported 5 districts to initiate and implement a community based distribution of contraceptive program. Populations in the CBDI (community based distribution of Injectable family planning) project areas receive individual FP counseling, condoms, pills and injectables from trained CBDs. They also receive family planning talks during outreaches and group talks from CBDs. CBDs promote different contraceptives both long and short term methods and refer to other contraceptive service provision points within their location. In addition, CBDs keep monthly records of their activities, including numbers of new, re-supply, and referral clients, as well as the number of contraceptive dispensed. Several studies on community based family planning provision have documented high levels of client acceptability from both client and provider perspectives and also client satisfaction [27, 28, 29, 3, 3]. Much as evidence shows that CBD can promote access among populations in which geographical distances or stigma around contraceptive use could deter access, no studies on community-based access to contraception have yet focused on youths and therefore evidence that CBD is successful at increasing contraceptive uptake among young people is limited. This study was based on a Community Based FP programme that has been operating in Busia District, Uganda using volunteers at village level since 28. The CBD programme is run by the district health team with support from the USAID through FHI36. The aim of the study was to 5

18 assess the uptake of contraceptives among youths aged 5-24 years within the project area of CBDFP in Busia district, Uganda. The study also examined the factors influencing uptake of contraceptives among this age group and their perceptive of the existing contraceptive services..3 Statement of the Problem Uptake of contraceptives among youths in Uganda is still low at percent largely due to limited access to contraceptive services especially in rural areas. National plans and guidelines for Sexual and Reproductive Health encourage use of community health workers within Village Health Teams to provide contraceptives, including the injectables, as a key intervention to promote access among underserved populations. However, there is hardly any studies on community-based distribution of contraceptives that has focused on youths and therefore evidence on CBD approach reaching youths and the factors that influence community based contraceptive uptake among youths are not well understood. Without evidence to inform such approaches, large numbers of underserved populations like youths will continue to miss out on reproductive health services and therefore suffer the consequences of unwanted pregnancies i.e. abortion, maternal morbidity and mortality that might otherwise be avoided or at least lessened. The aim of the study was to assess the uptake of contraceptives among youths aged 5-24 years within the project area of CBDFP in Busia district, Uganda. The study also examined the factors influencing uptake of contraceptives among this age group and their perceptive of the existing contraceptive services..4 Significance of the Study The study identified challenges and opportunities in the current FP service delivery approaches in addressing the FP needs of youths and therefore this information is expected to inform family planning programming to improve contraceptive service provision for young people in order to reduce unintended pregnancies. 6

19 The results of this study could also be used to strengthen future development of health service delivery to youths, and guide Ministry of Health and partner organizations, in the national wide scale up of CBD family planning. The study findings also provide insights on youths sexuality and therefore informative to the design of dual protection programs for HIV prevention among youths. 7

20 2. LITERATURE REVIEW This section reviews studies and documentations related to the uptake of contraceptives among young people and the factors which influence their use of contraceptives. The review of literature is discussed under two sections which include; youths sexuality and contraception and factors influencing the uptake and use of contraceptives by youths. 2.Background Information on Youths Sexuality and Contraception 2.. Sexual Behaviors of Youths in Sub-Saharan Africa The sexual health of youths is a matter of public concern. The adverse consequences of unsafe sexual behavior such as pregnancy and sexually transmitted infections (STIs) including HIV infection affect youths as well as adults. Risk taking behaviors are common when adolescents start being sexually intimate and are often linked with other health risk behaviors. Having sex for the first time at an early age is often associated with unsafe sex, in part through lack of knowledge, lack of access to contraception, lack of skills and self-efficacy to negotiate contraception, having sex while drunk or stoned, or inadequate self-efficacy to resist pressure [32]. Studies from Africa show that young people are becoming increasingly active sexually at early age. In Uganda, young people typically become sexually active, marry, and bear children early in life. By 5 years of age, percent of Ugandan adolescents have initiated sex and by 8 years 64 percent of young people have had their first sexual encounter [33]. In Kenya, 62 percent of never married male students age to 7 years and 3 percent of females had already had sexual intercourse. The median age at first intercourse was 4 for males and 7 for females [34]. Whereas in South Africa, a national survey of contraceptive use and pregnancy among women age 5-25 years old showed that 67.9 percent reported ever having had sex.. At age 24 years over two third of young South African women are sexually active and 5 percent have been pregnant, yet only half have ever used contraceptives. The high level of sexual activity and unprotected sex are placing these young women at risk of HIV infection and pregnancy [35]. 8

21 A multinational study conducted in four Sub-Saharan African nations shows contrary to what might be generally thought, very many adolescents in these four Sub-Saharan African countries are not all sexually naïve. Almost one-third of 2 4 year old girls and boys in Uganda and boys in Malawi have either experienced some form of intimate sexual activity such as sexual intercourse, kissing, fondling or they have had a boyfriend or girlfriend. This proportion is much lower in Burkina Faso and Ghana, but even in these two countries about in very young adolescents have had some sort of intimate sexual activity, ranging between 7 2% [36] Contraception among Youths in Uganda Contraception has been identified as an effective means of combating the problems of unwanted pregnancy and unsafe abortion [37]. It is an effective means of family planning and fertility control and therefore very important in promoting maternal and child health. The barrier methods are also useful in prevention and control of sexually transmitted infections (STIs) including HIV/AIDS. In the developing world like Uganda, unwanted pregnancy, unsafe induce abortion, high fertility rates, high maternal mortality rates, sexually transmitted infections and HIV/AIDS are very serious reproductive health problems that require urgent attention [38]. Literature suggests that, in general, sexually active unmarried adolescents are not seeking to become pregnant, and married adolescents wish not to become pregnant at a young age or, if they have already had a child, wish to delay a second pregnancy [39]. However, despite Uganda's liberal family planning policy, which states that all sexually active men and women should have access to contraceptives without need for consent from partner or parent, contraceptive use remains low, one of the lowest in the world. Awareness of contraceptives is almost universal, with 97.5 percent of people in reproductive age being able to identify at least one contraceptive method [7]. But only eight percent of married women aged 5-9 and sixteen percent of those aged 2-24 use modern contraceptive methods. Five percent of married youth aged 5-24 rely on traditional methods. Furthermore, 63 percent of sexually active unmarried women 5-9 years and 43 percent of sexually active unmarried women 2-24 years are not using any contraceptive method at all [7,2]. Condom use is low in Uganda; only two percent among married women 9

22 aged 5-24 use condoms. It is worth noting that contraceptive use is two times lower in rural compared to urban areas [7]. There is a mismatch between the desire to restrict birth and the actual use of contraception despite the wide spread knowledge and efficacy. Two of five young women aged 5-24 want to space or limit childbirth but are not using contraceptives [8] Contraceptive Preferences among Youths The male condom is the most commonly used modern contraceptive among young people in many countries. A four-country study conducted in sub-saharan Africa found that at least half of sexually active males aged 5 9 who reported having sex with more than one partner in the past three months said they had used a condom [4]. According to Bankole s study, condom use was highest among male adolescents in Ghana (68 percent) and lowest in Malawi (5 percent). On the contrary, data from Demographic and Health Surveys [4] show that oral contraceptives or injectables are the most popular hormonal method among 5 to 24 year-olds in the developing world, with rates of use exceeding 2 percent in some countries. Far fewer young women use implants, with rates of use below percent nearly everywhere. Data from the same surveys shows that despite the high awareness of hormonal methods among youth, there is much lower rates of use among adolescents ages 5 to 9 years than among young adults ages 2 to Contraceptive Practices among Youths Contraceptive practice among young people appears to involve much experimentation and inconsistent use. Contraceptive continuation over sustained periods of time is not assured, and discontinuation occurs for a number of reasons. Discontinuation is a particularly important issue for adolescents and young women because they tend to have more limited access than older individuals to family planning, as well as more unpredictable and irregular sexual activity, and are probably less knowledgeable about how to use contraceptive methods effectively[42]. According to a study of six developing countries women younger than 25 were more likely than others to stop using their contraceptive method after 24 months [43]. Similarly, Demographic and Health Surveys from 22 developing countries showed that women ages 5 to 9 are more likely than older women to stop using contraception within a year of starting [43]. Another, a study of about, women using oral contraceptives, injectables, or the intrauterine device

23 (IUD) in Benin found that the one-year cumulative probability of discontinuing any of the methods was about 74 percent for women younger than 2, compared with 43 percent for women ages 2 to 3 and about 38 percent for older women [44]. When the results in the Benin study were analyzed according to the contraceptive method used, age remained significantly associated with the risk of discontinuing oral contraceptives, especially during the first three months of use. 2.2 Factors Affecting Contraceptive Use among Young People Several studies have been done in the different countries in the past to find out the factors that affect individual's use or non-use of contraceptives. Literature shows an interaction of individual, societal and reproductive health service factors affecting young people's ability to access contraception. Individual factors include: - demographic, socioeconomic, Socio-cultural factors while reproductive and sexual health services factors include: - the characteristics of the facilities, the design of services, and providers' attitudes and actions Individual Factors Demographic factors: The demographic characteristics such as age, gender, educational status, number of living children and desire for additional children play an important role in determining the use of contraception. In addition, ethnicity, marital status, age, and gender all shape clients' experiences with family planning and reproductive health services. In some cultures, women may be unwilling to receive care from male providers, or husbands may object to having their wives see male providers, so a shortage of female providers may limit women's access to services. According to Velasco and colleagues, women in Bolivia, who were often too shy to discuss contraceptive use with their husbands, expressed even greater fear about talking to a male provider [45]. Further still, education also influences contraceptive uptake. A study in Kenya by Lasee and Becker (997) revealed that if the husband lacked schooling but the wife had some higher education, they were 4.3 times likely to use contraceptive compared to uneducated couples. According to the researcher, one interpretation of this result was that in case the wife was better educated than her husband, she might have considerably more household

24 decisions-making [46]. On the contrary, a study in Mexico by Nazar-Beutelspacher indicated that non-use of contraception was higher among the illiterate women than among those who had completed secondary schooling (49 per cent vs. 3 per cent) [47]. Related to the above is knowledge about contraception. According to Jejeebhoy SJ and colleagues, inadequate knowledge about contraception and how to obtain health services is one of the reasons why many adolescent women in developing countries are especially vulnerable [48]. Inadequate knowledge about contraception brings fears, rumors, and myths about family planning methods and can prevent young people from seeking contraception. In one survey in Uganda, some participants gave reasons why they would fail to use contraceptives even if they did not intend to get pregnant. Many participants, both male and female distrusted male condoms, the contraceptive used most frequently by young people. They believed that it was potentially be dangerous to use condoms because it could get stuck in the vagina where it would get rotten and cause damage. Likewise there were rumours that the pill could cause deformed babies, inability to get pregnant in the future as well as cancer of the cervix and the breasts [49]. Rumors and myths about family planning may raise potential clients' concerns about the side effects, safety, and effectiveness of different methods. Another study in Uganda found that young people believed that contraceptives interfered with their fertility, and they were frightened to use something that could harm their ability to reproduce. In the same study by Nalwadda et al, most of the married and unmarried women believed that pills burned the woman's eggs [5]. Socio-cultural factors: In many parts of the world, women do not have the decision making power, physical mobility, or access to material resources to seek family planning services. Women's use of contraceptives is often strongly influenced by spousal or familial support of, or opposition to family planning. Research in northern Ghana found that women who chose to practice contraception risked social ostracism or familial conflict [5]. In some areas, women need their husband's permission to visit a health facility or to travel unaccompanied, which may result in either clandestine or limited use of contraceptives [52]. 2

25 Additionally, Stigma around young people s sexuality may similarly deter young people from seeking such services or may result in denials of reproductive health services, even where parental consent is not required. Many sexually active young women report fear, embarrassment, or shyness about seeking family planning services [53]. Furthermore, Family planning methods sometimes challenge bio-cultural beliefs. For example, women in some societies believe it is healthy to menstruate monthly, and therefore refuse to use injectable contraceptives that often result in irregular bleeding, spotting, or amenorrhea (no monthly bleeding). A Tanzanian woman lamented providers' discussions of the advantages of Depo-Provera: "They talk of it as the best family planning method despite the fact that we miss our monthly periods when we use it. A woman is not perfect if she doesn't get her monthly periods" [54]. Providers sometimes ignore such concerns because they do not consider them clinically significant. Understanding clients' beliefs can help providers align their services with these ideas or, when necessary, address local misconceptions. Providers can also bridge such gaps by expressing respect for the clients' beliefs and drawing connections between these beliefs and medical models of health [55]. On the other hand, socio-economic factors have been shown to be of greater importance than demographic factors in influencing the use health services [56]. In fact, fees for transportation, services, and supplies, can be a major barrier to contraceptives for many young people. Cost is a significant obstacle for adolescents, as young people frequently lack their own source of income or control over their finances to be able to afford contraceptives [57]. Even free or low-cost reproductive and other health care involves costs, including the opportunity cost of time away from income-generating activities [58]. In addition, competing demands on women's time can also make it difficult for women to use services, particularly when facilities are far away. Child care, food preparation, household sanitation, maintaining fuel and water supplies, and income-generating work outside the home can make seeking health care seem like a luxury Reproductive Health Service Factors 3

26 Surveys reveal that young people do not want to run into family members and neighbors when entering, utilizing, or leaving reproductive health facilities. But still, many youth have difficulty traveling very far away, unless public transportation is available. Other facilities-related barriers include: a lack of privacy; no area set aside where young people can wait to be seen; and setting that is overly clinical, too adult, and or welcoming only to women and not also to men. Privacy and Confidentiality: Clients feel more comfortable if providers respect their privacy during counseling sessions, examinations, and procedures. Particularly those who obtain services in secret report higher satisfaction with providers who keep their needs and personal information confidential [59]. Lack of privacy can violate women's sense of modesty and make it more difficult for them to participate actively in selecting a contraceptive method. In a few places, obtaining and using contraceptives can be a difficult and risky decision that can lead to abandonment, violence, ostracism, or divorce. In such situations, women need assurance of absolute confidentiality. Method Choice and Availability: Clients want a variety of services. Providing a wide range of contraceptive methods can help clients find those that match their health circumstances, lifestyle, and preferences [6]. In an assessment of nine countries, the percentage of women who said that they would rather be using a different method ranged from percent (Mauritius) to 48 percent (Costa Rica). Respondents cited several reasons, including the cost of their preferred methods, difficulty obtaining their current methods, medical ineligibility for other methods, and family disapproval of certain methods [6]. Supply shortages can lead to dissatisfaction; as a result, some clients may discontinue using family planning altogether. Substantial evidence is found in the literature for how broadening the choice of contraceptive methods results in increased overall contraceptive prevalence [62, 63]. The provision of a wide range of contraceptive methods increases the opportunity for individuals to obtain a method that best suits their needs [64]. 4

27 The Design of Services: Research identifies several features in the design of services that may actively discourage youth's using the services. Design obstacles include, but are not limited to, cost, crowded waiting rooms, counseling spaces that do not afford privacy, appointment times that do not accommodate young people's work and school schedules, little or no accommodation for walk-in patients, and limited contraceptive supplies and options. Hearing about these obstacles may prevent young people from making a first visit. Encountering these obstacles may discourage them from returning. Convenient Schedules and Waiting Times: Long waiting times and inconvenient clinic hours can prevent clients from obtaining the services they need. In both Malawi and Senegal, clients identified long waiting times as a concern. One client said, "The wait is a big problem. I'll sometimes skip my appointment if I think about the hours I'll have to spend at the center" [65 ]. Some clinics do not post their hours of service, or do not serve clients during certain hours when they are supposed to be open. A study in Kenya found that although clinics were officially open from 8 a.m. to 5 p.m., providers discouraged clients from coming in the afternoons and often did not provide services to women who were only able to attend in the afternoon [66]. Information and Counseling: Clients want to receive information that is relevant to their needs, desires, and lifestyles. Because clients differ in their reproductive intentions, attitudes about family planning, ability to make decisions, and other factors that affect contraceptive choice, they need information that is tailored to their individual needs. Clients who are well-informed and have made their choice about a contraceptive method may not want detailed information on a range of other methods. Others may want information about procedures, treatment, risks, and side effects. In a study in Kenya, women were not satisfied with the information provided; they wanted to hear about a larger number of methods so that they could make an informed choice [67]. Over 4 percent of the women in one Indonesian study wanted more information on side effects, and over 26 percent wanted to know more about how contraceptives work [68]. A study of,57 Norplant users in Indonesia found that women who had received counseling and information about Norplant were more satisfied than those who had received less information [69]. Similarly, the Davao Project in the Philippines demonstrated that lack 5

28 of client counseling, lack of privacy for counseling, and high clinic caseloads were major weaknesses in the province's family planning program [7]. Affordability of Services: Clients are generally more likely to use low-cost services. In Kenya, clients said that low costs and proximity of services were the two most important factors that attracted them to services [64]. A study in Bangladesh indicated that families spent money on health care only in a crisis situation. Contraceptive side effects and related problems are rarely seen as emergencies, so many women in the study stopped using contraception or switched methods because they could not justify the expense of dealing with side effects [7]. On the other hand, clients may be willing to accept higher costs if they believe that services are of high quality. Providers Attitude and Actions: Provider attitudes, opinions, and biases about contraceptives represent what providers truly believe, including their support or opposition to provision, and opinions potentially affecting distribution practices. Research shows that some family planning providers still restrict access to contraceptives based on age or marital status [72]. In many societies and cultures, adults have difficulty accepting youth's sexual development as a natural and positive part of growth and maturation. Young people are not encouraged to seek care if they encounter providers whose attitudes convey that youth should not be seeking sexual health services. Young people may be embarrassed and refuse to return for services if staff asks personal questions loudly enough to be overheard by others. Furthermore, service providers sometimes deny access to a family planning method as a result of their own prejudices about the method or its delivery system. Provider bias, which occurs when service providers believe that they are in a better position to choose the most appropriate method for the client, or are biased toward certain methods, may preclude women from using a method appropriate to their circumstances and needs. One woman in Kenya explained, "I asked them to give me the injectable. They told me that the pill was okay with me and I couldn't receive the injectable with only two children. I decided to stop and have never gone back" [7]. If clients do not receive their preferred 6

29 method or service, or are turned away without receiving satisfactory diagnoses, they may stop seeking care. In addition to the above, studies have shown that women are more likely to seek out and continue using family planning services if they receive respectful and friendly treatment [7,73]. In many societies, courtesy is a sign that the client is regarded as the provider's equal. Research shows that the provider's tone, manner, and modes of speech are important to clients [74]. In one study in Zaire, most women who were asked about the two best qualities for a nurse first mentioned qualities related to communication style, such as respect and attentiveness, and second listed technical qualities [75]. 2.3 Research Questions and Objectives 2.3. Research Questions o What proportion of sexually active youths use contraceptives? o Where do youths obtain contraceptives at community level? o How do youths use contraceptives (contraceptive practices)? o What are the factors that influence youths uptake of contraceptives at community level? General Objective. To assess the uptake of modern contraceptives and the factors which influence uptake among youths (5-24 years) within the project area of CBDFP in Busia district, Uganda. in Busia district, Uganda Specific Objectives. To determine contraceptive prevalence rate among youths in Busia. 2. To describe use and preferences of contraceptives among youths in Busia. 3. To establish the factors which influence uptake and use of contraceptives among youths at community level in Busia? 4. To explore young people s perceptions towards receiving contraceptives from the different service providers at community level. 5. To explore community based provider s perspectives on provision of contraceptives to youths. 7

30 2.4 Conceptual Framework Uptake of modern contraceptives among youths is believed to be influenced by a complex interaction of many factors at individual, social and reproductive health service delivery levels. Individually, age, parity, education and knowledge about contraception do influence uptake of modern contraceptives. Socially; cultural norms, marital status, partner/family support, designated gender roles and the demand for bigger families influence the individual s conception choices. In addition, peer pressure; religious teachings and policy influence freedom of choice of a contraceptive method. Also, reproductive health service delivery factors such as attitudes and skills of the providers, method specific side effects, availability of methods, ease of use and access of contraceptive method do act directly or indirectly to influence uptake of contraceptives. Diagrammatic conceptual framework Societal / socio support factors o Peer / Partner support o Gender roles o Cultural norms Individual Factors o Demographic factors i.e. age, gender, education, marital status etc. o Socio-cultural factors i.e. decision making powers, desire for children etc. o Socio-economic factors like cost of services, transport Acceptance of Contraceptives Contrace ptive Use among youths Reproductive health service factors o Choice of care i.e. Public health facility, Private for profit (drug shops and clinics), CBD and outreach o Method Choice and Availability o Design of services i.e. cost of services, waiting time etc. o Provides attitude and actions o Assemblage of services 8 Continuation of contraception

31 3. METHODOLOGY This chapter outlines the techniques that were used in obtaining and utilizing the data for this study. It contains research design, study population and area, the procedure of selecting the sample size, research instruments, quality control, data collection, analysis and limitation of the study. 3. Study Design This was a descriptive cross sectional study conducted between May to August 22 in Busia district, Uganda. Both quantitative and qualitative study methods i.e. survey, FGDs and in-depths interviews were used to collect detailed views of research participants in response to the research questions. Qualitative analysis enabled the researcher generate a detailed description of uptake and use of modern contraception among youths of different social background. 3.2 Study Area and Population 3.2. Study Area The study was conducted in Busia district. Busia was purposively selected because it has the largest and oldest CBD program, of all districts supported by FHI36. FHI36 is an international not for profit organization. In Uganda FHI 36 s work is around improving access to family planning among underserved communities. Busia is located in the eastern region of Uganda and it s about 87 kilometers from Uganda s capital city. Busia represents any rural community in Uganda. The main activities in the study area include agriculture with main emphasis on food crops such as millet, potatoes, beans, simsim and sunflower; fishing on Lake Victoria and some cattle keeping are also practiced. Busia district is one of the 5 districts currently supported by FHI36 to implement a community-based distribution of contraceptives program under the STRIDES and PROGRESS projects. The CBD project covers all sub counties of Busia district apart from the town council. The district has one hospital, two H/C IVs, seven H/C IIIs and 8 H/C IIs. With nine sub counties, 537 villages and 47,886 households, Busia district currently has a population of 28, 5 people compared to the 225 people estimated in the 22 9

32 population and housing census of Uganda. In 2-2, Busia district had 56,782 women in the reproductive age with 4,55 pregnancies and 3633 births. Busia district contraceptive prevalence rate is still low at 37 percent and lower for the age group 5-24, [76] even though its slightly higher than the national contraceptive prevalence rate Study Population and Sample The study population comprised of sexually active youths between ages 5-24 years. A mixture of both married and unmarried youths were considered in the study irrespective of their educational and occupational status. The study population also included contraceptive service providers within the study area. The sampling frame was the list of all youths between ages 5-24 years from the six randomly selected villages of Buhehe Sub County. The samples were youths (5-24) from the six study villages of Buhehe who reported being sexually active and volunteered to participate in the study Sample Size The study sample size was 323 youths from six villages of the two study parishes and was determined basing on three factors: the estimated contraceptive prevalence rate for youths (in this case, 3% is an average for the 5-9 and 2-24 sub-groups); the confidence level at 95%; and the margin of error at 5%. The formula below was used to calculate the sample size. n= t 2 xp(-p) m 2 Where: n = required sample size t = confidence level at 95% (standard value of.96) p = estimated contraceptive prevalence rate for youths (5-24) at national level m = margin of error at 5% (standard value of.5) Sampling Procedure Multi-level sampling was used in this study. Different sampling techniques were used as explained below; 2

33 Selection of the Study District: Busia district was purposively selected because it had many contraceptive service delivery approaches among the two the districts supported by fellow while on her field placement at FHI36. Selection of Study Sub Counties: Simple random sampling was used to select a study Sub County. The names of the eight sub counties with trained community based distributors of contraceptives were typed and printed out separately. Each printout was uniformly folded and put into a non-transparent envelop. The envelopes were then poured on the floor and the principle investigator randomly picked one paper. The envelope picked was opened and the selected Sub County (Buhehe) considered the study sub county. Selection of Study Parishes: Because of time and financial limitations, two out of the three parishes in Buhehe Sub County were selected as study parishes. Simple random sampling was used to determine these parishes. The names of the three parishes in Buhehe were typed and printed out separately. Each printout was uniformly folded and put into a non-transparent envelop. The envelopes were then poured on the floor and the principle investigator randomly picked two papers, one after the other. The envelopes picked were then opened and the selected parishes of Bulwenge and Buhasaba considered as the study parishes. Selection of Study Villages: Six villages were purposively sampled into the study, considering three villages per parish. These included; Buyuha, Busiera, Bulenge, Bujwanga, Dhaka and Buckaki. Distance from a community based distributor was factored in while selecting of the villages. A village where a CBD lives was automatically be considered in each parish as well as a village at the extreme end of the CBD catchment area (which is a parish). The third village per parish was chosen basing on its geographical location within the parish. Using a parish map and with guidance of parish leaders, a central village (between village and 2) was selected into the study. Identification and Sampling of Study Subjects for the Survey: Prior to the study, a meeting was held with a local council leader from each of the six villages. During this 2

34 meeting, the principal investigator explained the purpose of the study to the local leaders and requested for their invaluable contribution and support towards the study. In this meeting, dates to carry out the survey and focus group discussions were set. The meeting also agreed on when to carry out the identification exercise of the study subjects. Village council heads were facilitated and came up with a list of all youths eligible to be study subjects. Inclusion Criteria All sexually active married youths who were between 5-24 years and residents of the six study villages were included in the study. Similarly, sexually active unmarried youths who were between 8-24 years and residents of the six study villages were also considered for this study. In addition, even sexually active unmarried youths (5 and 8 years) who were residents of the six study villages and whose parents or guardians permitted their participation in the study. Exclusion Criteria The study excluded visiting youths in the selected villages and all youths below 5 years or above 24 years. A list of all names of youths within the study villages (generated by the authorities) served as a sampling frame and a basis to proportion the sample size amongst the six villages. It also helped at calculating the sampling interval which guided the sampling of study subjects from the framework. The first respondent who was included in the study will be randomly selected from the sampling frame by the principle investigator and thereafter, every 5th person was circled and considered study subject. After sampling, the authorities were informed of the study subjects and requested to notify the selected youths to allow participation in the study. Research assistants then moved to the respective homes of the sampled youths to carry out the interviews. If the selected youth reported not being sexually active or declined participating, the interview was stopped and the research assistant moved on to another sampled youth. Incases were the first sampled lot was exhausted before reaching the expected proportion of respondents in a given village; the principle investigator sampled another lot from the framework, using the same procedures. 22

35 Identification of FGD Participants: The contraceptive service providers in the study areas were used to identify and select 24 young clients to be included in the study. This was done purposively considering most revisit clients first. The participants together with their providers chose the ideal time, place and length of the focus group discussions. For the non contraceptive users (24 youths), selection was done by participants of the FGDs of contraceptive users. These were requested to each identify a friend who is sexually active but not using contraceptives. The eligible youths were then contacted and together with the researcher, chose the ideal time, place and length of the focus group discussions. Non CBD clients were considered to get their views on the factors affecting their uptake of contraceptives from CBDs. In-Depth Interview Participants: The study also involved contraceptive service providers from the study parishes. Four CBDs, two drug shop operators and two health workers in the study sub county were purposively selected into the study as key informants and were interviewed in length to capture their attitudes and perceptions towards dispensing contraceptives to youths Study Variables In this study, the dependent (outcome) variable was contraceptive use among youths 5-24 years old whereas independent variables will include; contraceptive uptake, age, religion, marital status, occupation, educational background, distance from service provider, supportive partner, number of children, number of siblings, fertility desires, quality of services and provider s attitudes. 3.3 Data Collection Procedures Data were collected with the help of ten research assistants who had completed at least advanced level of education (more than 2 years of education) and conversant with the indigenous language in the study district (Samia). The research assistants were oriented on the research objectives, quality control, record taking and research ethics prior to the beginning of data collection process. They traveled to the villages at pre-arranged dates to conduct the survey. Door to door interviews were conducted in local languages at the 23

36 respective communities, and each interview lasted 45 to 6 minutes. The questionnaires were interviewer administered. FGDs: These were conducted by a research assistant with the help of the researcher. Hand written notes were taken during the dialogues. From these notes, a detailed report was written at the end of each FGD. In-Depth Interviews with the Service Providers: These were conducted by the researcher. The interviews were conducted in both English or local language depending on the language the respondent was comfortable with. Interviews were carried out at the respective community, and each interview lasted at most two hours. The interviews were recorded to eliminate the interruptions of notes taking in the course of the interview. The audio taped information was used by the researcher for reference purposes Tools The study used three methods of data collection and each of these components is described briefly below: Survey Questionnaire: For the population Survey, a semi-structured questionnaire was developed and used to collect data from youths. The questionnaire contained both closed and open ended with spaces for explanation where was required. Open-ended questions were used to provide greater depth on experiences, views, and attitudes of youths. The questions and structuring of the questionnaire was informed by findings from review literature. In-Depth Interview Guide: An in-depth guide was developed and used to guide faceto-face in-depth interviews with service providers. In-depth Interviews (IDIs) generated rich and detailed information concerning service provider s readiness to dispense contraceptives to youths. Open ended lead questions were used to probe the subject of discussion. The tool was translated into the local language (Samia) to ensure uniformity and validity and accuracy of the dialogues. The interview was recorded using a mini disc recorder. Similarly, the in-depth interview guide was pre-tested and feedback used to refine it. 24

37 Focus Group Discussion Guide: An FGD guide was developed and used to guide face- to-face discussions with young CBD clients and potential clients. The FGDs were conducted in the local environment with participants in each group familiar to one another. FGD method was appropriate because it is relaxed and enabled participants to freely participate. A focus group guide was used to guide the discussions. The tool was translated into the local language to ensure uniformity and validity and accuracy of the dialogues. In the course of the FGD, hand written notes were taken by the research assistant while exchanging facilitation roles. 3.4 Data Management, Quality Control and Analysis 3.4. Data Management For qualitative data, all filled questionnaires were reviewed by principal Investigator and statistician for consistence and data quality, and then entered using Epi info version For qualitative data, every day, the hand written notes were taken during the dialogues. These were reviewed and a detailed report written for each dialogue. The raw data and community dialogue reports were harmonized and revisited time and again to ensure accuracy and quality control. The audio taped in-depth interviews (in the local language) were transcribed and then translated in English. The local language terminologies were not translated into English so as to reserve their informative meanings intact Quality Control and Assurance To ensure the quality of the data collected, the following safeguards were carried out: Recruited and trained research assistants: Recruited and trained research assistants who were skilled in quantitative and qualitative techniques. The research assistants were also oriented for two days, on the research objectives, quality control, record taking and research ethics prior to the beginning of data collection process. Day one of the orientation involved face to face talk and mock interviews and day 2 involved fieldwork to familiarize with the data collection tools. This was aimed at ensuring accuracy, consistent, uniformity and validity of the dialogues. 25

38 Forth and back translation of the tools: The FGD and IDI guides were forth and back translated into the local language to ensure uniformity and validity and accuracy of the dialogues. Pre-tested the tools: The questionnaire, in-depth interview guide and FGD guide were pre-tested and refined according to feedback generated from the pre-testing exercise before data collection started. This exercise was to validate the appropriateness of the tools, whether it was too long or not, difficult or easy to understand, checked for clarity of the questionnaire items and eliminated ambiguity, difficult wordings or unacceptable questions. Participants were given the opportunity to comment on the clarity of the questions and they were requested to make suggestions for improvement. Daily debriefs and closely supervised of research assistants: The principal researcher closely supervised the research team, reviewed each collected questionnaires on a daily basis and held daily debriefs with the whole research before departure for fieldwork. Daily report writing: Every day, the hand written notes were taken during the dialogues. These were reviewed and a detailed report written for each dialogue Data Analysis For qualitative data, codes (numbers) were made for different themes (variables). The coding process was done after data had been entered into a computer according to its respective source. In the process of entering data into a computer, a template form was created and arranged information according to the identified themes. Coding of the data and the analysis was done manually. The unit of analysis was the focus group and IDI respectively. Latent content analysis technique that involves in-depth interpretation of the underlying meanings of the text and condensing data without losing its quality was used. The analysis was discussed among the research team members and discrepancies on coding and other issues that required clarity were settled by discussion. Quotes that best 26

39 described the various categories and expressed what was aired frequently in several groups were chosen. For qualitative data, since the study was mainly descriptive, frequency/percentage distribution tables, graphs and cross-tabulations were the main form of presentation and analysis for the study. Quantitative data from the survey was analyzed using SPSS XBM version 4 statistical package. The analysis focused on uptake of contraceptive. Logistic regression techniques were also employed to examine the factors which influenced contraceptive use among youths at community level. The dependent variable was assessed against most the independent variables. 3.5 Ethical Considerations Ethical Review and Approval Process: The researcher sought ethical approval from the higher degrees, research and ethics committee of the School of Public Health, Makerere University and the Uganda National Council for Science and Technology. Informed consent: Research assistants informed all study participants of their rights and risks of participating in the study. Written consent was obtained from all study participants after explaining the purpose of the study. For participants below 8 years old and not married, consent was sought from their parents. Participants below 8 years old and not married also assented to participate in the study. Two consent forms were developed for both parents or guardians and youths above 8 years. Sexuality being a sensitive subject, the consent forms did not mention the fact that participants must be sexually active. Instead they pointed out that participants may be required to share personal experiences on contraception. After obtaining consent, participants were subjected to screening questions to exclude those who were not sexually active. Prior to each survey, FGD and IDI, research assistants read informed consent forms to participants and parents in the appropriate local language. All participants and parents or guardians for unmarried youths below 8 years had to give their written consent before the research assistants 27

40 preceded with the interview. A copy of the consent form, with the name, phone number, and address of representatives of the UNCST was offered to every participant. For those who declined taking their copy of the consent form, it was stored with the study copy in a secured file. The signed informed consent sheets were detached from the questionnaire and kept in a separate location so that they cannot be linked. No names were recorded on the data collection forms. Participation in the study was voluntary and married adolescents between the ages of 5 and 8 were considered mature minors since they were staying with their spouses. Therefore, since they did not need parental permission to obtain services, consent for the study was sought directly from them without parental consent. Parental consent sought if a youth is unmarried and below 8 years old. Throughout this study, privacy and confidentiality was emphasized. All data was collected in a private setting. Confidentiality was assured by use of identifiers and restriction of raw data to only the principal researcher. Study limitations o There was some information bias since a few of the questions asked were related to sexuality. However, this was minimized by the interviewers moving in pairs of male and female, hence the interviewees given a chance to select their preferred interviewer. This enabled participants to choose their preferred interviewers. o There was difficulty in tracing study participants since youths are a mobile group and data collection was done during school days. However, this was minimized by repeated returns to participants homes and then replacements were made in cases where the repeated returns didn t yield much. 28

41 4. RESULTS 4. Introduction This chapter presents the study findings according to the study objectives. Some of the typical or deviant views from respondents have been quoted in this chapter. 4.2 Demographic Characteristics of Respondents 4.2. Socio-demographic Characteristics of Respondents A total of 323 sexually active young people participated in the survey. The mean age of the respondents was 9.5 years, age range was 5-24, and 5% of the respondents were between ages 5-9 while 49% between 2-24 years. Female respondents constituted the biggest proportion (62%) of the study respondents while 3% (43/323) of the study respondents were married and below 2 years. Ninety four percent of respondents were of the Samia tribe and this confirmed that the study area was predominantly a Samia settlement. Most of the respondents (88%) were literate (could read and write). However, only 35% had reached secondary level and 2.5% had joined tertiary institutions. Majority of the respondents (48.9%) were peasant farmers while 34.7% still in school. This showed that youths out of school mainly depended on subsistence farming. The details can be seen in the table below. 29

42 TABLE : Socio-demographic Characteristics of Respondents Variable Age Sex Marital status Religion Education level Tribe Occupation Frequency (N=323) Percent (%) % % Female 99 62% Male 24 38% Single 66 5% Married 57 49% Christianity % Islam 3.9% Others 4.2% None 2 3.7% Primary school % Secondary school 3 35% Tertiary education 8 2.5% Samia % Basoga 3.9% Itesot 4.2% Japadhola.3% Others 3.% No other work.3% Farmer % Student % Vendor/Shop owner 9 2.8% Teacher 2.6% House wife % Others 6 5.% Sexual and Reproductive Behaviors and Experiences of Respondents Findings on sexual and reproductive behaviors and experiences showed that 6% of all respondents were having multiple sexual partners while 53% of all respondents reported not knowing their partners HIV status. A bigger proportion of the respondents (52.6%) 3

43 had given birth, with 2.5% having more than two children. Four of the respondents with the highest number of children had 5 children at 24 years, three of whom were females. Data on fertility desires showed that majority of the respondents (75.4%) desired to have four children or fewer despite many respondents (46.6%) having seven or more siblings. This can be seen in the table below; TABLE 2: Sexual and Reproductive Behaviors and Experiences of Respondents by Contraceptive Uptake. Variable Frequency [n=323(n %)] Contraceptive uptake (Freq) Yes [n=2] No [n=22] No. of sexual partners 27 (83.9%) 67 (83%) 4 (85.2%) 2 and above 52 (6.%) 34 (6.9%) 8 (4.7%) Knowledge of HIV status Yes 237 (73.3%) 54 (76.6%) 83 (68%) No 86 (26.7%) 47 (23.3%) 39 (3.9%) Knowledge of partners HIV status Yes 5 (46.8%) (5.2%) 5 (4.9%) No 72 (53.2%) 99 (49.2%) 73 (59.8%) STI protection Nothing 68 (2.%) 2 (.9%) 66 (54.%) Condom use 39 (43%) 39 (69.) - Faithfulness 3(35%) 59 (29.3%) 54 (44.2%) Others 3 (.9%) (.4%) 2 (.6%) No. of children 53 (47.3%) 93 (46.2%) 6 (49.%) -2 3 (4.2%) 82 (4.7%) 48 (39.3%) (2.5%) 26 (2.9%) 4 (.4%) Fertility desires 4 children 244 (75.5%) 49 (74.%) 95 (77.8%) 5children 79 (24.4%) 52 (25.8%) 27 (22.%) No. of siblings 4 siblings 78 (24.%) 48 (23.8%) 3 (24.5%) 5 siblings 245 (75.8%) 53 (76.%) 92 (75.4%) 3

44 4.3 Use and Preferences of Contraceptives among Respondents 4.3. Contraceptive Prevalence Of all the 323 sexually active youths (5-24) interviewed, prevalence of use modern contraception (all methods) was at 62.2%. Use of other modern contraception other than condoms was at 26%. Nonuse of any modern contraceptive was high at 37.8% considering that all the interviewees were sexually active. Fourteen percent of the 22 respondents who were not currently using modern contraceptives, reported ever used any method in their life time. Nonuse of modern contraceptive was common among nonmarried females below 2 years. This can be seen in table 3. TABLE 3: Socio-Demographic Characteristics of Respondents by Modern Contraceptive uptake Variable Freq (n %) Modern contraceptive use Yes (n=2) No (n=22) Age (5.%) 97(48.2%) 68(55.7%) (49%) 4(5.7%) 54(44.2%) Sex Female 99 (6.6%) 22(6.6%) 77(63.%) Male 24 (38.3%) 79(39.3%) 45(36.8%) Marital status Single 66 (5.3%) 4(5.7%) 62(5.8%) Married 57 (48.6%) 97(48.2%) 6(49.%) Schooling status In-school 2 (34.6%) 68(33.8%) 44(36%) Out of school 89 (44.2%) 33(66.%) 78(63.9%) 32

45 4.3.3 Modern Contraception Preferences of Respondents Condoms were found to be the most preferred contraceptive method at 7.7%, followed by Depo-provera at 3.8% and pills at 9%. This finding matched with the findings of the question on preferred contraception where majority of the respondents (52%) mentioned condoms as their preferred method, followed by Depo-provera at 38%. Other than condoms, Depo-provera and pills, the other modern contraceptive methods (implant and IUD) were not reported being used by the respondents. Only 8/2 (9% ) current users of modern contraceptives, reported either having switched or used more than one contraceptive method in the twelve months preceding the study. The bar graph below illustrates contraceptive methods used by age group and marital status of respondents. FIGURE : Contraceptive Method Used by Age Groups and Marital Status of Respondents. Reasons for Preference Current contraceptive users cited several reasons for their preferences ranging from; easy to use, cheap, long duration, privacy and fewer side effects. Majority of the respondents (47.2%) preferred a method which was easy to use while 8.8% liked a method which 33

46 was less expensive and 7% because of privacy. These findings matched with the focus group discussions where youths mentioned that they preferred a method which could easily be used. One participant remarked: I just go to musawo (provider) and within a minute am given my injection. Even if my boyfriend doesn t use a condom or incase its bursts, I will have a backup protection. Female participant, FGD Contraceptive Use Behaviors and Practices among Respondents Findings on contraceptive use behaviors and practices showed that there was a lot of inconsistent use and early discontinuation of contraceptive methods among youths who reported using modern contraceptives. Thirty six percent of all current users of contraceptives reported having used contraceptives for less than six months and only 5% had used any method consistently for 2 years and above. This finding matched with the FGD findings were one respondent remarked: Condom use: After giving birth to my baby, I decided to use contraceptives. I went for esindani (injectable contraceptive) but it treated me badly. I developed pain in the tubes and also bled a lot. When I went to Masafu hospital and explained my problem, I was just told to go back home and wait until the duration of the injection is over and I go back for checking. I never went back but I remember one health worker told me that all that was caused by the injectable. I decided not to use it again. Female participant, FGD 4 Furthermore, findings on condom use behaviors and practices also revealed improper and inconsistent use of condoms among youths. Only % of condom users reported using condoms correctly and consistently (used condoms every time and round of sex) while 9% used condoms once in a while. Seventy one percent of condom users reported either having used condoms only during the first three months of their relationships; or every time they had sex but not every round of sex; or every round of sex but not every time they had sex. Discussions with condom users during the focus group discussions also 34

47 revealed improper and inconsistent use of condoms among youths. One participant remarked: My penis is small and the condom cannot fit. I use a rubber band to tie it in order to be able to use it. Male participant, FGD 2 I know my wife can easily conceive immediately after her menstruation, that s when I use condoms. I only use condoms during these first four days following her menstruation. Male participant, FGD 3 Oral Contraceptive use: Oral contraceptive pill users reported a lot of omissions and discontinuation of pills. Fifty nine percent of pill users reported swallowing a pill everyday while 29% swallowed prior to sexual intercourse and 2% either left out the brown pills or swallowed contraceptive pill once in a while. One FGD participant reported using emergency contraception as her regular contraceptive method. She remarked: Whenever I have sex, I rush to a drug shop there at the trading center and buy emergency contraceptive pills. They have protected me for over two years now and every time I swallow them, am safe. Female participant, FGD 3 Use of Depo-provera: On the other hand, findings on the behaviors and practices related to use of Depo-Provera showed high rates of early discontinuation among Depo-provera users. The findings showed that the higher the number of Depo-provera injections taken consecutively, the fewer users. Most Depo-provera users (39.3%) had not taken three or more injections consecutively. This indicated that youths dropped out after nine or less months of using Depo-Provera. This can be seen in figure 2: FIGURE 2: Depo-Provera Injections taken consecutively by Injectable Users 35

48 4.3.5 Source of Contraceptives at Community Level Out of the 2 youths who reported using contraceptives, 56 percent obtained the services from government health facilities, 22 percent obtained from drug shops, while 4 percent obtained from CBDs. On the other hand, a paltry five percent obtained contraceptives from ordinary shops. These results clearly pointed out that government health facilities are the main providers of contraceptives among youths. FIGURE 3: Source of Contraceptives at Community Level 36

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