“Some rumors can make you fear to use the methods”: A qualitative analysis of barriers to the utilization of modern family planning services among adolescent girls and young women in rural Northern Uganda

doi:10.21203/rs.3.rs-4946592/v1

Download PDF

Research Article

“Some rumors can make you fear to use the methods”: A qualitative analysis of barriers to the utilization of modern family planning services among adolescent girls and young women in rural Northern Uganda

https://doi.org/10.21203/rs.3.rs-4946592/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Introduction:

Modern family planning services are crucial for sexually active Adolescent Girls and Young Women (AGYW) to prevent unintended pregnancies.

Objective

To explore the barriers to the utilization of modern family planning services among AGYW in Oyam District, Northern Uganda.

Methods

We conducted a qualitative study involving eight focus group discussions (FGDs) each with ten respondents, who were AGYW, aged 15–24 years residing in Oyam district Northern Uganda. The FGDs lasted 60–90 minutes and they were audio-recorded. Audio recordings were transcribed verbatim and Open Code software was used to evaluate the data using both an inductive and deductive thematic approach.

Results

Four main themes emerged as barriers to modern family planning services use. First, opposition to family planning including; religious, male and cultural opposition. Secondly, health concerns such as side effects related to family planning use. Thirdly, health systems factors such as low availability of family planning methods and long waiting time at the health facilities and lastly, rumors and misconceptions.

Conclusion

The barriers to the utilization of modern family planning methods among AGYW in Oyam District, Northern Uganda were consistent with those observed in other studies around the world. Interventions to improve access to modern family planning services among this population can be implemented under three broad themes. (1) Alleviating opposition to family planning, (2) Addressing health concerns related to family planning such side effects plus misconceptions/rumors and (3) Improving the quality of family planning services. For these interventions to be effective, they should be directed to the individual, the family/intimate partner, and the community at large.

Modern family planning services

adolescent girls and young women (AGYW)

Northern Uganda

Adolescent girls and young women (AGYW) still remain a very important target population for sexual and reproductive health services [1] as their pattern of conduct is more significantly associated with sexual affection [2]. Contraceptive use among AGYW in Sub-Saharan Africa is still low [3–5] despite having a high prevalence of unintended pregnancy [6]. In low- and middle-income countries (LMICs), problems associated to pregnancy and childbirth are the primary causes of maternal mortality[7, 8].

In Northern Uganda, the prevalence of modern family planning (FP) services use is still very low among AGYW [9].

In 2020, Oyam district had the highest level of teenage pregnancy in Northern Uganda [10].

We explored the barriers to the utilization of modern family planning services among AGYW (15–24 years) in Oyam District, Northern Uganda.

Study setting

We conducted this study in the twelve sub-counties of Oyam District, Northern Uganda, Lango sub- region. Oyam became a district on July 1st 2006, having been curved out of its mother district of Apac. While still under Apac, Oyam was the largest county.

Participant enrollment and data collection.

We conducted 8 focus group discussions (FGDs) with the adolescent girls and young women aged 15–24 years in Oyam district. Purposive sampling method was used to select the study participants based on their location and ability to actively participate in a focus group discussion with guidance from the Sub-county chiefs and Local Council One chairpersons. We included adolescent girls and young women aged 15–24 years in the focus group discussions.

The research team members introduced themselves and also explained the study objectives to the participants. The research team members obtained written informed consent from each participant and thumb prints were provided by those who could not read and or write in the presence of a witness. After obtaining consent, FGDs were conducted following a semi-structured interview guide in leb Lango (the local language spoken in Oyam district). These FGDs were conducted in quiet environments convenient for participants to avoid disruptions. The FGDs lasted between 60–90 minutes, were audio recorded, and reflective notes were recorded by the researchers. The participants received time compensation of twenty thousand Ugandan shillings in addition to transport refund.

Data analysis

All audio-recorded focus group discussions were transcribed verbatim and analyzed thematically in Open code software using the following steps as described by Braun and Clarke [11]: data familiarization, coding and theme identification and refinement. The results are accompanied by quotes directly from the respondents as authentic supporting sources.

Ethics

We obtained ethical approval from the institutional review board (IRB) at Gulu University with the reference number GUREC-2022-356. Written informed consent was obtained from all respondents, as well as the parents or legal guardians of each respondent under the age of 18, which was accompanied by signatures from literate respondents and a thumbprint from illiterate respondents and a witness’ signature.

Socio-demographic characteristics of the participants.

The median age of the participants was 19 years with interquartile range (17–22 years), majority of whom 80% (64/80) were Catholics with 52.5% (42/80) being single and 55% (44/80) having at least one child. (Table 1)

Table 1

Socio-demographic characteristics of the 80 participants who participated in the focus group discussions (FGDs).
Variable	Category	Median(Q1,Q3)	Overall n(%)
Age		19(17,22)
Marital status	Married		38(47.5)
	Single		42(52.5)
Number of children	0		36(45.0)
	1		26(32.5)
	2		14(17.5)
	4		4(5.0)
Religion	Catholic		64(80.0)
	Anglican		6(7.5)
	Pentecostal		8(10.0)
	Moslem		2(2.5)

(Q1, Q3)-Interquartile range

Barriers to the utilization of modern family planning services.

Opposition to family planning.

Religious opposition

According to the majority of respondents, using modern family planning services is hampered by their religious beliefs.

“…the way I think about these methods of family planning, I don’t like it so much, I always think that if there was some way God could intervene (all laughed) He should help us because I find that the side effects are many sometimes, I think it is a punishment from God because those who worship God and are so deep in the spirit condemn it and preach against it.” (FGD1, 18-year-old, PAG)

“I am a catholic, in our church, they (Catechists and priests) always say when you are wedded, you are not supposed to use family planning, you should continue to produce.” (FGD8, 20-year-old)

“In my religion, PAG, they say it (modern family planning methods) is from Satan so anything to do with family planning, my religion does not support it.” (FGD6, 18-year-old)

Male opposition

Although men reportedly refuse their partners from using modern family planning methods, they have also been reported to encourage their women to use modern FP methods.

“My husband does not accept, he says I should produce and lift the status of the clan and he says if you go for it do not come back to my home.” (FGD2, 20-year-old)

“I wanted to go for implants but my husband refused saying I should first give birth to one child so I didn’t go for it.” (FGD7, 19-year-old)

Cultural opposition

Numerous participants stated that their cultural customs hinder them from using family planning.

“Culture does not believe in family planning directly because I saw my sister was married and she used implants, when her in-laws realized, they started insulting her that she is just filling the latrine for nothing(laughter) that if she is not producing, let her return home.” (FGD1, 21-year-old)

“Culture supports the use of herbal medicines than modern family planning methods and it (herbal medicines) is found with the old women, they always give to those who have given birth to many children on condition that you can keep secret.” (FGD5, 20 year old)

“Our culture does not support the use of modern family planning methods, they say once you have been married, you have to produce children and that you should add the population of the clan.” (FGD3, 20-year-old)

Health concerns related to modern family planning methods use.

Side-effects

The side effects of using modern family planning continue to be one of the factors influencing its use.

“I once accessed family planning service, I used implants for three years, I felt a lot of body pain and bleeding, went to the health centre and I was advised to first remove it, when I did so, the bleeding stopped, even the pain stopped.” (FGD5, 18 year old)

“I have used these methods but it is hard for me to use; because I injected myself since march last year and this is April, I have just seen my menstruation two days ago, I don’t know the duration it will take because I stayed for one year minus seeing it.” (FGD2, 24 year old)

“I once used a family planning method, injectaplan, it caused me a lot of bleeding. Now I have left it.” (FGD4, 23 year old)

Rumors and misconceptions

Rumors and misinformation spread by family and community members have a substantial impact on the usage of modern family planning services.

Rumours

“The one that I have heard that can discourage me is that when you have used a method and after you get pregnant, when you go for delivery, you experience much labor pain.” (FGD8, 21-year-old)

“Sometimes you can be there hearing many things, other rumors can make you fear to use the methods. I had a friend that is very close to me, she said she used implant, when she went to remove, it was not got, this gave me fear.“ (FGD6, 24-year-old)

“People say if you use them when you are still a young girl you cannot conceive, it can burn your ovaries.” (FGD2, 17-year-old)

Misconception

People are being discouraged from using family planning services since there are still a lot of misconceptions about it. Family planning is seen negatively by many people.

“The problem associated with the use of family planning is that if you have used for so long when you get pregnant, you have to experience miscarriage or you give birth to abnormal child.” (FGD6, 20-year-old)

“This one that they swallow, called pill something – not sure of the name, don’t you think it can cause problem/ I think it can accumulate in your body.” (FGD8, 21-year-old)

“I once heard about some people who used emergency pills, almost three people who have been using it for a long time, now they cannot conceive.” (FGD 7, 18-year-old)

Health systems factors

Availability of modern family planning methods.

The government health centers' stated shortage of contemporary family planning methods forces respondents to seek care at private clinics, where they occasionally lack the funds to cover the costs of family planning procedures.

“Sometimes when you go to the health Centre you might find that the medicines are not there but in clinics, they are readily available and different methods.” (FGD3, 19-year-old)

“You can get it (modern family planning methods) from the health centre and sometimes from the clinic but sometimes when you go to the clinic, they always say the medication is over, so mostly we get it from the Health Centre.” (FGD1, 20 year old)

“You can go to the health centre and medicines get finished when others have not got. I once went to the health centre and found out the medicines are over.” (FGD8, 15year old)

Waiting time at the health facility

Because they have other things to do with their time, respondents cited the health center's lengthy wait times and the clinic's quicker service as factors influencing their use of modern family planning methods.

“The only place where you can get these services (family planning) faster is the clinic, when you go to the health centre, they can tell you to wait yet some other things cannot wait.” (FGD1, 24-year-old)

“In most cases when you go to the health facilities, in case you do not get, it means, it just got finished, only what disappoints me is waiting time when I go to the health centre.” (FGD6, 18-year-old)

“...but just the duration. Sometimes the nurses go away and just be doing nothing, so since you have gone for free services, you have to wait which is not so good.” (FGD7, 18-year-old)

The results of this study indicate that there are still barriers to modern FP use among AGYW (15–24 years) in rural Uganda. These include; opposition to FP, health concerns related to FP, health systems factors, rumors and misconceptions.

Our study show that cultural opposition is still a big hindrance to modern FP use, this is because culture supports the use of herbal medicines than modern FP services. This finding is similar to those from two studies detailing how family planning use among AGYW in Uganda is impacted by cultural variables, quality of modern family planning services and availability [12, 13]. Our study also highlights the significance of misconceptions and side effects as a barrier to use of family planning. This is similar to a study in Mozambique where AGYW thought that modern FP could make them infertile [14] and that it could lead to miscarriage, dysmenorrhea, amenorrhea or the implant could get lost into her body [15, 16]. Religious teachings against family planning also have a significant bearing against its modern FP services use. This confirms findings from Nigeria and Ghana where religious teachings against FP was a big hindrance to modern FP use [15, 17]. Male opposition is still an impediment to modern FP use in rural Uganda, this affirms other studies from Ghana and Mozambique where girls reported that some men strongly resisted modern FP use [14–16]. Quality of health services is also a strong facet of family planning usability. Just like in our study, AGYM expressed concerns against stock outs of family planning methods at the health facilities, long waiting time and unavailability of staff to attend to them [17, 18]. Finally, community has a strong say in the use of family planning. Our study found that family members advised AGYM against use of family planning because they wanted them to reproduce and build the family. These same findings were reported in Guinea and Nigeria [17, 18].

The main barriers to the utilization of modern family planning services among AGYW (15–24 Years) in Oyam District, Northern Uganda were opposition to family planning, health concerns, health systems factors and rumors and misconceptions. Family and community rumors were important decision-influencing factors when it came to using modern family planning services, suggesting that family planning programs should target more than just the individual.These factors highlight the significance of men's roles, cultural and religious beliefs, and the lack of agency that most women have when it comes to making reproductive health decisions.

Funding

This research was funded with support from Center for International Reproductive Health Training at University of Michigan (CIRHT-UM). Though it may not always reflect the official opinions of CIRHT-UM, the content is the writers' alone responsibility. The decision to publish, the plan of the study, the gathering and analysis of data, or the writing of the report was all outside the purview of the funders. Pre-Publication Support Service (PREPSS) supported the development of this manuscript by providing author training, as well as pre-publication peer-review and copy editing.

Author Contribution

V.A: Conceptualized the study, designed the methodology, acquired funding, analyzed the data and wrote the original manuscript draft.F.B : Contributed to the study design and project administration, reviewed and edited the manuscript.D.K: Assisted in training the research assistants and edited the manuscript.S.V.L: Assisted in training the research assistants, data collection and edited the manuscript.

Acknowledgement

We would like to acknowledge all the adolescent girls and young women who accepted to participate in this study, the research assistants Brenda Apio, Candy Akello, Joyce Ajok, Scovia Ajok and Suzan Acen. We also acknowledge the funders of this study, Center for International Reproductive Health Training at University of Michigan (CIRHT-UM) as well as Pre-Publication Support Service (PREPSS) that supported the development of this manuscript by providing author training, and pre-publication peer-review and copy editing.

Data Availability

The audio-recordings that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Wilson A, et al. Sexual and reproductive health among adolescent girls and young women in Mombasa, Kenya. Sex reproductive health matters. 2020;28(1):1749341.
Bongaarts J. United Nations department of economic and social affairs, population division world family planning 2020: highlights. United Nations publications. Popul Dev Rev, 2020. 46: pp. 857–858.
Tsui AO, Brown W, Li Q. Contraceptive practice in sub-Saharan Africa. Popul Dev Rev. 2017;43(Suppl Suppl 1):166.
Behrman JA et al. Trends in Modern Contraceptive Use among Young Adult Women in sub-Saharan Africa 1990 to 2014. Studies in family planning, 2018. 49(4): pp. 319–344.
Radovich E, et al. Who meets the contraceptive needs of young women in sub-Saharan Africa? J Adolesc Health. 2018;62(3):273–80.
Ayalew HG, et al. Prevalence and factors associated with unintended pregnancy among adolescent girls and young women in sub-Saharan Africa, a multilevel analysis. BMC Womens Health. 2022;22(1):1–9.
de Coll VN. Contraception in adolescence: the influence of parity and marital status on contraceptive use in 73 low-and middle-income countries. Reproductive health. 2019;16:1–12.
Organization WH. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization; 2023.
Bakesiima R, et al. Modern contraceptive use among female refugee adolescents in northern Uganda: prevalence and associated factors. Reproductive Health. 2020;17:1–9.
Uganda U. Fact sheet on teenage pregnancy. Kampala: United Nations Population Fund; 2021.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.
Ivanova O, et al. A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda. Reproductive health. 2019;16:1–11.
Tanabe M, et al. Family planning in refugee settings: findings and actions from a multi-country study. Confl health. 2017;11:1–12.
Capurchande R, et al. It is challenging… oh, nobody likes it! a qualitative study exploring Mozambican adolescents and young adults’ experiences with contraception. BMC Womens Health. 2016;16(1):1–17.
Boamah-Kaali EA et al. A qualitative exploration of factors explaining non-uptake of hormonal contraceptives among adolescent girls in rural Ghana: The adolescent girls’ perspective. Open Access J Contracept, 2021: p. 173–85.
Babore GO, Heliso AZ. Contraceptive utilization and associated factors among youths in Hossana town administrative, Hadiya zone, Southern Ethiopia. PLoS ONE. 2022;17(11):e0275124.
Ezenwaka U, et al. Exploring factors constraining utilization of contraceptive services among adolescents in Southeast Nigeria: an application of the socio-ecological model. BMC Public Health. 2020;20:1–11.
Manet H, et al. Factors facilitating the use of contraceptive methods among urban adolescents and youth in Guinea: a qualitative study. Reproductive Health. 2023;20(1):1–13.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
21 Aug, 2024
Editor assigned by journal
20 Aug, 2024
Submission checks completed at journal
20 Aug, 2024
First submitted to journal
20 Aug, 2024

You are reading this latest preprint version

“Some rumors can make you fear to use the methods”: A qualitative analysis of barriers to the utilization of modern family planning services among adolescent girls and young women in rural Northern Uganda

Status:

Version 1

Abstract

Introduction:

Objective

Methods

Results

Conclusion

Introduction

Methods

Study setting

Data analysis

Ethics

Results

(Q1, Q3)-Interquartile range

Rumors and misconceptions

Health systems factors

Discussion

Conclusions

Declarations

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

Version 1