Determinants Underlying Teenager’s Accessibility to Contraceptive Methods and HIV Preventive Measures in Rwamagana District, Rwanda

doi:10.21203/rs.3.rs-4992580/v1

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Research Article

Determinants Underlying Teenager’s Accessibility to Contraceptive Methods and HIV Preventive Measures in Rwamagana District, Rwanda

https://doi.org/10.21203/rs.3.rs-4992580/v1

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Background: In Rwanda, despite significant political achievements in women's empowerment and efforts to eliminate child sexual abuse, the rate of teenage pregnancy remains high. Increased access to and use of contraceptive methods could reduce the rates of teenage pregnancy and HIV infection.

Objectives: This study aims to assess the determinants, needs, and barriers to the use of contraceptive methods and HIV/AIDS preventive services by adolescents in Rwamagana District, Rwanda.

Methods: A cross-sectional design was used in this study. A multistage sampling strategy with a simple random technique was employed to select 376 female students as participants. Data were collected using a pretested questionnaire composed of closed-ended questions with Likert scale constructs based on the Theory of Planned Behavior. Descriptive statistics, bivariate analysis, and multivariable logistic regression were conducted.

Results: A multiple logistic regression analysis shows that participants aged 18–20 are more than twice as likely to use contraceptive methods or HIV preventive measures compared to those aged 13–15 (OR=2.876, P=0.041, 95% CI=1.974–4.052). Urban participants are also more than twice as likely to use contraceptives or HIV preventive methods compared to those whose schools are in rural areas (OR=2.333, P=0.037, 95% CI=1.261–4.316). Female students in Senior 6 are more than three times as likely to use contraceptive methods or HIV preventive measures compared to those in Senior 1 (OR=3.444, P=0.032, 95% CI=2.544–6.884).

Participants who intend to have sex at an older age had a 24.9% reduction in the odds of using a contraceptive method or HIV preventive measures (OR=0.751, P=0.033, 95% CI=0.352–0.977). Friends of respondents also influence contraceptive use (OR=0.611, P=0.043, 95% CI=0.252–0.917). Participants with contraceptive knowledge are three times more likely to use contraceptives or HIV preventive methods compared to those with less contraceptive knowledge (OR=3.096, P=0.011, 95% CI=1.150–6.803).

Conclusion: Area of residence, age, friendships, and knowledge of contraceptive methods and HIV preventive measures are the determinants underlying early sexual activity among teenagers. One of the biggest challenges is the level of sex education, which remains a taboo topic in Rwandan culture. It is still difficult for parents to discuss sex directly with their children. We recommend further studies to focus on teenage non-scholars while conducting similar research.

Adolescent reproductive health

Contraceptive methods

HIV preventive measures

Teenage pregnancy

Sociodemographic factors

Sexual health education

A recent report of a study done in four (two urban and two rural) districts in Rwanda on the provision of adolescent-friendly sexual and reproductive health (AFSRH) services and attitudes of healthcare workers indicated that access to sexual and reproductive health (SRH) services forms a crucial building block of health systems.¹ Poor access to SRH services can result in early and unintended pregnancies, maternal mortality, HIV and sexually transmitted infections (STIs), as well as complications from untreated STIs, such as pelvic inflammation, specific types of cancer, and pregnancy and fertility issues. Unfortunately, Rwanda experiences many challenges with the adequate provision of AFSRH services. Chandra-Mouli et al. noted that substantial, albeit uneven, progress has been made in reducing levels of adolescent childbearing and in meeting adolescent contraceptive needs over the last 25 years.² However, there is still much work to be done in both these areas.

Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality for both the mother and the child. Use of condoms as a measure to prevent pregnancy as well as HIV infection is very important. According to the Rwanda Demographic and Health Survey (2019–2020), adolescent childbearing has negative social consequences, particularly in terms of educational achievement, as teenage mothers are more likely to drop out of school.³ The data shows that 5% of women aged 15–19 have started childbearing, with 4% having given birth and 1% being pregnant with their first child.³ Since 2014/2015, the percentage of teenagers who have given birth or are pregnant with their first child has decreased from 7–5%.³ Tasamba added that a total of 17,337 underage girls got pregnant in 2017, and up to 19, 832 in 2018, according to official data.⁴ 23,544 children were born to teen mothers in 2019. In Rwanda, the average HIV prevalence rate is likely to be high among girls aged 15–19 (0.9%) compared to their male counterparts (0.3%), and 90% of women agree that teenagers ages 12–14 should be taught how to use condoms to prevent HIV infection.³

In addition, adolescents acknowledge that commercial sex exists and discuss the types of people that they thought become involved in it: the poor or those lacking sex education.⁵ Teen mothers are susceptible to being infected by HIV due to their acceptance of sexual offers: the poor economic conditions that follow unwanted pregnancy may lead to increased vulnerability to acquiring HIV through offering sex at any price when they need resources to survive.⁶ This risky situation exposes them to several complications (infection, school dropout, sex workers, poverty etc.), and mortality may be the result, especially in low resource settings.^7,8 Although some services have been incorporated in Rwanda, adolescent reproductive services significantly impact the accessibility of contraceptive methods and HIV preventive measures.⁹ The factors influencing access include healthcare-related issues, the cost of contraceptives, a shortage of skilled healthcare workers, long waiting times, lack of privacy at clinics, insufficient comprehensive sexuality education, misconceptions about contraceptives, and non-friendly services.⁹ The Rwamagana District has a population of 484,953, representing approximately 13.6% of the Eastern Province.¹⁰ The population of Rwamagana District is predominantly composed of youth, with approximately 56.05% of the resident population being under the age of 25.¹⁰ The population of 10–19-year-olds is 107,745, which represents 22.21% of the population of Rwamagana District.¹⁰ In Rwamagana District, 305 teenagers experienced pregnancies between July 2021 and June 2022, with 150 of these pregnancies occurring during the COVID-19 pandemic.¹¹

Therefore, the World Health Organization in its guidance and recommendations about the provision of contraceptive information and services highlight the right to the highest attainable standard of health, as well as the rights to education and information.¹² These rights have been applied by international, regional, and national authoritative human rights bodies. These organizations include those that handle a wide range of sexual and reproductive health issues, including the accessibility of contraceptive information and services, which comprises of accessible contraceptive cost; distance to services; modern contraceptive prevalence; contraceptive uptake by new users; and adolescent contraceptive use.

Although barriers exist, the involvement of all stakeholders (parents, health professionals, policy makers, and educators) is key to overcoming them and reducing this gap in sexual health and safety. Considering the continued prevalence of teen pregnancy and HIV exposure, there is a need to explore determinants underlying teenager’s accessibility to contraceptive and HIV preventive services in Rwamagana.

Definition of concepts

The World Health Organization defines adolescence as the phase of life between childhood and adulthood, encompassing ages 10–19.¹³ This is a unique stage of human development and a crucial period for establishing the foundations of good health. Adolescents undergo rapid physical, cognitive, and psychosocial growth, which influences how they feel, think, make decisions, and interact with the world around them.

The United Nations defines "youth" as individuals between the ages of 15 and 24.¹⁴ In Rwanda, the legal age is 16, but the legal age for marriage is 21. This study adopts the term "teenage" to refer to the age group of 10–19-year-olds.

Specific method aims

This study, conducted in the Rwamagana District, aimed to achieve several objectives. First, it sought to identify the sociodemographic characteristics of secondary school teenagers. Second, the study aimed to identify the sociodemographic factors that determine teenagers’ access to contraceptive methods and HIV preventive services. Third, it aimed to determine the components of the theory of planned behavior (TPB) underlying teenagers’ access to these services. Fourth, the study sought to identify statistically significant factors influencing teenagers’ accessibility to contraceptive methods and HIV preventive measures. Lastly, based on the findings, this study aimed to propose suggestions for improving existing strategies for contraceptive methods and HIV preventive services.

Framework

The theoretical framework of this research is based on Ajzen's TPB (1988).¹⁵ This theory has been proven effective in evaluating the factors contributing to the explanation or prediction of health behaviors across various populations, particularly for behaviors that are under partial volitional control, as is the case in this study.¹⁶ The TPB provides clear benchmarks for understanding its constructs, and its dimensions are easily operationalized.¹⁷ Moreover, understanding the links between the factors associated with the use or non-use of contraceptives and HIV preventive measures, as well as the beliefs of individuals regarding their use, is essential for the future establishment of an intervention program aimed at preventing unwanted pregnancies and HIV infection (see Fig. 1). The purpose of this study is dependent on this understanding.

This cross-sectional descriptive study with a quantitative approach was conducted in the Rwamagana District. The targeted population consisted of secondary school girls from Senior 1 to Senior 6 in public schools. A sample size of 388 was selected from a total of 12,682 female students from 62 secondary schools using Slovin's Formula, where n = N / (1 + Ne²), with a confidence level of 95% and a margin of error of 5%. After data collection and analysis, the final sample size was 374, representing 96.3% of the target population, which provides very good representativeness.

Purposefully, we decided to sample six schools in urban sectors and three schools in rural areas. The lists provided by the heads of schools were used as the sampling frame, and a multistage sampling strategy was employed. A simple random technique, with probability proportionate to the number of female students in each school, was used to generate the sample size for each school. Figure 2 shows the multistage sampling method used.

Multistage sampling

Legend: So = Sovu, Rwa = Rwamagana, Bi = Bicumbi, Mw = Mwurire, Mu = Muyumbu, Bu = Bujyujyu, Sh = Shyogoshyo, Bw = Bwana, Ny = Nyamatete.

Figure 2. Multistage sampling strategy used.

Measurements

The study's questionnaire included closed-ended questions related to the measurement of TPB variables as well as the sociodemographic characteristics of the participants. The questions measuring the TPB variables were scaled according to the Likert scale as described in Gagné et al.¹⁸

Intentions

Intentions for risk reduction behaviors were rated on a 5-point scale (1 = Strongly Disagree to 5 = Strongly Agree). Condom use intentions were assessed using 2 items (r = 0.74, p < 0.01): “In the next few months, I will not have sex unless I use a condom,” and “In the next few months, I’ll make sure I have condoms anytime I think I might have sex.” Intentions to delay sexual activity were assessed using 2 items (r = 0.80, p < 0.01): “In the next few months, I will not have sex,” and “I will not have sex in the next few months because I want to wait until I am older.”

Perceived behavioral control

Perceived behavioral control was assessed using a 10-point scale (1 = Very Sure I Cannot to 10 = Very Sure I Can). There were 4 items on the condom use subscale (e.g., “How sure are you that you can use a condom every time you have sex?”), and 4 items on the delay subscale (e.g., “How sure are you that you can wait to be old to have sexual intercourse?”).

Perceived norms

Participants rated items about perceived norms on a 5-point scale (1 = Strongly Disagree to 5 = Strongly Agree). The condom use subscale included 6 items (r = 0.74, p < 0.01), and the delay subscale also included 6 items. The perceived norms scales incorporated both descriptive norms (e.g., “My friends in TPB always use condoms during sexual intercourse”) and subjective norms (e.g., “My boyfriend or girlfriend thinks it is okay or even good to wait until you’re older to have sexual intercourse”).

Attitude

Participants responded to items regarding their behavioral beliefs and outcome expectations, which underlie attitude formation (Ajzen, 1985). These items were rated on a 5-point scale (1 = Strongly Disagree to 5 = Strongly Agree). There were six items (r = 83, p < 0.01) on the condom use subscale (e.g., “If I use condoms every time I have sex, I won’t enjoy having sex”), and five items on the delay subscale (e.g., “I’ll be doing what’s best for me if I don’t have sex until I’m older”).

The questions addressed sociodemographic characteristics and components of the TPB (attitudes toward the use of contraceptive methods, subjective norms that might influence their use, and perceived behavioral control). Data collected were related to the accessibility of contraceptive methods and HIV preventive measures.

Validity and reliability

The tool used in this research was developed by Icek Ajzen. Authorization for its use was provided by Ajzen himself. The questionnaire was then adapted to the Rwandan context, and a pilot study was conducted with 20 female students. The reliability of the tool was assessed using Cronbach's alpha, which resulted in a coefficient of 0.829, indicating a statistically good correlation between the items. These 20 female students were excluded from the study.

Ethics consideration

The proposal for this study was submitted to and approved by the institutional review board of the University of Rwanda, which provided ethical clearance. The questionnaire was anonymous and irreversibly de-identified, using only numerical codes to differentiate participants from different schools. The management, accessibility of the raw data, and their intended purpose were explained and guaranteed to the participants. An informed assent form, providing information about the research, was signed by the heads of schools for all female students, both those living in boarding facilities and those staying at home. Additionally, a consent form was signed by the respondents.

Data collection and management

Data collection for the study was carried out using a self-administered questionnaire distributed directly by the researchers. Beforehand, the purpose of the study, guidelines for completing the questionnaire, ethical considerations, and the specific questions were thoroughly explained to the participants. Each questionnaire was completed immediately after distribution and returned to the researchers. All data were collected within the same week across all schools.

Analysis

Data analysis was performed using Statistical Package for the Social Sciences software version 24. Descriptive statistics were carried out for each variable. Bivariate analysis was conducted to assess the association between the independent variables (sociodemographic characteristics, components of the TPB, and individual characteristics toward sexual and reproductive health) and the dependent variables (contraceptive methods and HIV preventive measures). The significance level was set at 0.05. Independent variables that showed a significant association were included in a multiple logistic regression to study their effect on the dependent variable. Odds ratios, which quantify the strength of the association between independent and dependent variables, were computed, and confidence intervals (CI) were estimated to indicate the probability that a population parameter will fall between a set of values for a certain proportion of times.

1. Sociodemographic information of participants

Table 1

Sociodemographic information of participants.
Variables	n	%
Age group (years)
13–15	141	37.7
16–17	128	34.2
18–20	105	28.1
Marital status
Single	213	57.0
Single, not in relationship	57	15.2
Single, in relationship	96	25.7
Separated, divorced, or widowed	8	8.2
Religion
Catholic	132	35.3
Protestant	228	61.0
Muslim	14	3.7
Location of the school
Rural	257	68.7
Urban	117	31.3
Social Welfare category¹
Category A	43	11.5
Category B	136	36.4
Category C	167	44.7
Category D	25	6.7
Category E	3	0.8
Live at boarding school
Yes	336	89.8
No	38	10.2
Level of study
A level	138	36.9
O level	236	63.1

Table 1 presents the sociodemographic information of the participants. The study results showed that a large proportion, 141 (37.7%), were between 13 and 15 years old. Regarding marital status, 215 (57.5%) were single. A significant proportion, 228 (61.0%), identified as Protestant, and the majority, 257 (68.7%), lived in rural areas. In the participants population there were not married or in relationship no single.

The mother’s occupation was assessed, revealing that a large proportion, 279 (74.6%), were cultivators/farmers. The study also assessed the fathers' occupations, showing that 236 (63.1%) were cultivators/farmers. For fathers or father figures, 173 (46.3%) had attended primary school.

The standard of living, which is a common measure in Rwanda, indicated that a large proportion, 167 (44.7%), fell into welfare category C. Additionally, the majority of participants, 336 (89.8%), attended boarding schools. The Rwandan secondary school system is divided into two cycles: lower secondary (O level), consisting of Senior 1 to Senior 3, and upper secondary (A level), consisting of Senior 4 to Senior 6. Among participants, a larger proportion, 236 (63.1%), reported being in the O level than the A level.

2. Components of TPB

2.1. Perceived norms

Table 2

**Perceived norms toward the use of the contraceptive methods during possible sexual relations.**
Variables	Strongly disagree n(%)	Disagree n(%)	Neutral n(%)	Agree n(%)	Strongly agree n(%)
If I tell my boyfriend that I’m going to use condoms every time I have sex, they’ll agree this is best for me.	60(16)	28(7.5)	73(19.5)	67(17.9)	146(39.0)
If I tell my friends in THP that I’m going to use condoms every time I have sex, they’ll agree this is best for me.	58(15.5)	48(12.8)	53(14.2)	91(24.3)	124(33.2)
My boyfriend believes you should always use condoms during sex.	29(7.8)	30(8.0)	51(13.6)	91(24.3)	124(33.2)
My friends in THP believe you should always use condoms during sex.	36(9.6)	32(8.6)	36(9.6)	117(31.3)	153(40.9)
My boyfriend always uses condoms during sexual intercourse.	33(8.8)	44(11.8)	86(23.0)	107(28.6)	104(27.8)
My friends in THP use condoms during sexual intercourse.	35(9.4)	40(10.7)	79(21.1)	125(33.4)	95(25.4)

Perceived norms were assessed in this study, and the results showed that a significant number of respondents, 146 (39.0%), strongly agreed that if they told their boyfriends they were going to use condoms every time they have sex, their boyfriends would agree that this is best for them. Similarly, 124 respondents (33.2%) strongly agreed that if they told their friends they were going to use condoms every time they have sex, their friends would also agree that this is best for them.

A large number of participants, 145 (38.8%), strongly agreed that their boyfriends should always use a condom during sex, and 153 (40.9%) strongly agreed that their friends believe they should always use condoms during sex. Among the participants, 107 (28.6%) agreed that their boyfriends always use condoms during sexual intercourse, and 125 (33.4%) agreed that their friends always use condoms during sexual intercourse.

Table 3

Delay to have sex
Variables	Strongly agree n(%)	Disagree n(%)	Neutral n(%)	Agree n(%)	Strongly agree n(%)
If I tell my boyfriend or girlfriend that I’m going to wait to have sex, they will agree this is best for me.	23(6.1)	25(6.7)	19(5.1)	106(28.3)	201(53.7)
If I tell my friends in THP that I’m going to wait to have sex, they will agree this is the best for me.	16(4.3)	34(9.1)	25(6.7)	106(28.3)	193(51.6)
My boyfriend or girlfriend thinks it is okay or even good to wait until you’re older to have sexual intercourse.	17(4.5)	26(7.0)	17(4.5)	116(31.0)	198(52.9)
My friends in THP think is okay or even good to wait until you’re older to have sexual intercourse.	17(4.5)	23(6.1)	22(5.9)	109(29.1)	203(54.3)
My boyfriend or girlfriend is waiting to have sexual intercourse.	26(7.0)	49(13.1)	46(12.3)	127(34.0)	126(33.7)
My friends in THP are waiting to have sexual intercourse.	28(7.5)	24(6.4)	43(11.5)	127(34.0)	152(40.6)

The majority, 201 (53.7%), strongly agreed that if they told their boyfriend or girlfriend that they were going to wait to have sex, their partners would agree that this decision is best for them. Additionally, 193 (51.6%) strongly agreed that if they told their boyfriends they were going to have sex, their partners would agree it is best for them. A large number of participants, 198 (52.9%), strongly agreed that their boyfriends think it is okay or even good to wait until they are older to have sexual intercourse. Similarly, 203 participants (54.3%) strongly agreed that their friends think it is okay or even good to wait until they are older to have sexual intercourse. Among respondents, 126 (33.7%) strongly agreed that their boyfriends are waiting to have sexual intercourse. Additionally, 152 (40.6%) strongly agreed that their friends are waiting to have sexual intercourse.

2.2. Attitude

Table 4

Attitude toward the use of the contraceptive methods during possible sexual relations.
Variables	Strongly disagree n(%)	Disagree n(%)		Neutral n(%)	Agree n(%)	Strongly agree n(%)
Condom use
If I use condoms every time I have sex, I won’t like having sex.	107(28.6)	53(14.2)		103(27.5)	66(17.6)	45(12.0)
I’ll be safe from unwanted pregnancy, HIV, and AIDS if I use condoms every time I have sex.	14(3.7)	13(3.5)		21(5.6)	90(24.1)	236(63.1)
I know I’ll be doing the right thing if I tell my friends that I’m going to use condoms every time I have sex.	23(6.1)	25(6.1)		23(6.1)	113(30.2)	190(50.8)
I’ll be doing what is best for me if I use condoms every time I have sex.	16(4.3)	30(8.0)		29(7.8)	86(23.0)	213(57.0)
I am doing the right thing if I tell my boyfriend or girlfriend that I’m going to use condoms every time I have sex.	20(5.3)		21(5.6)	30(8.0)	118(31.6)	185(49.5)
If I tell my boyfriend or girlfriend that I’m going to use condoms every time I have sex, I know it will strengthen my relationship with them.	23(6.1)		25(6.7)	19(5.1)	106(28.3)	201(53.7)
Delay having sex until older
I’ll be safe from HIV and AIDS if I wait until I’m older to have sex.	9(2.4)	11(2.9)		14(3.7)	65(17.4)	275(73.5)
If I tell my friends that I’m going to wait until I’m older to have sex, I know I’ll be doing the right thing.	2(0.5)	6(1.6)		18(4.8)	102 (27.3)	246(65.8)
I’ll be doing what is best for me if I don’t have sex until I’m older.	11(2.9)	10(2.7)		20(5.3)	77(20.6)	256(68.4)
I’ll know I am doing the right thing if I tell my boyfriend or girlfriend that I’m going to wait to have sex.	12(3.2)	11(2.9)		25(6.7)	92(24.6)	234(62.6)
If I tell my boyfriend or girlfriend that I’m going to wait to have sex, I know it will strengthen my relationship with them.	20(5.3)	32(8.6)		33(8.8)	124(33.2)	165(44.1)

This study assessed attitudes toward condom use, revealing that 107 participants (28.6%), strongly disagreed with the statement that using a condom every time they have sex would reduce their enjoyment. Conversely, the majority, 236 (63.1%), strongly agreed that using condoms every time they have sex would protect them from unwanted pregnancy, HIV, and AIDS. Among the participants, 190 (50.8%) strongly agreed that informing their friends about their intention to use condoms every time they have sex is the right thing to do. Additionally, 213 participants (57.0%) strongly agreed that using condoms every time they have sex is in their best interest.

Furthermore, 201 (53.75%) strongly agreed that telling their boyfriends about their intention to use condoms every time they have sex is the right thing to do, and 106 (28.3%) strongly agreed that doing so would strengthen their relationship.

A significant proportion, 275 (73.5%), strongly agreed that waiting until they are older to have sex would keep them safe from HIV and AIDS, and 246 (65.8%) strongly agreed that telling their friends they are going to wait until they are older to have sex is the right decision. Among the participants, the majority, 256 (68.4%), strongly agreed that abstaining from sex until they are older is in their best interest. A large proportion, 234 (62.6%), strongly agreed that informing their boyfriend about their decision to wait to have sex is the right thing to do, and 165 (44.1%) strongly agreed that such a decision would strengthen their relationship.

3. Individual characteristics regarding students’ sexual and reproductive history

Table 5

Sexual and reproductive history of students.
Variables	n	%
Have had sex
Yes	46	12.3
No	328	87.7
Age at first intercourse
10–14	14	30.4
15–17	15	32.6
18–20	17	37.0
Frequency of condom use during these sexual intercourse
Rarely	8	17.4
Frequently	12	26.1
Never	20	43.5
Sometimes	6	13.0
Sexually active currently
Yes	181	48.4
No	193	51.6
Knowledge of contraception
Yes	311	83.2
No	63	16.8
Have used a contraceptive method or an HIV preventive measure
Yes	184	49.2
No	190	50.8
Source of information about contraceptive method/HIV preventive measures
Friends	67	17.9
Parents	87	23.2
Mass media	90	24.0
Healthcare facilities	35	9.3
Youth center	66	17.6
Web pages	29	7.7

The majority of respondents, 328 (87.7%), have never had sexual relations in their lifetime. Among the 46 (12.3%) who have had sex, many (17, 37.0%) reported that the age when they first had sex was between 18 and 20 years old. Additionally, 14 (48.3%) of those who have had sex rarely use condoms. A significant proportion of respondents, 311 (83.2%), did not know what contraception was. Among the respondents, 190 (50.8%) have never used a contraceptive or HIV preventive method. Mass media was cited as their source of information on contraception/HIV preventive measure more than any others (90, 24.0%). A majority of participants, 210 (56.1%), said abstinence could be used for contraception.

Table 6

**Cross tabulation of sociodemographic information and use of contraceptives or HIV preventive methods.**
Variables			P-value
Use of contraceptive method or HIV preventive measure
	Yes n(%)	No n(%)	0.033
13–15	69(48.9)	72(51.1)
16–17	69(53.9)	59(46.1)
18–20	50(47.6)	55(52.4)
Marital status
Single	100(51.2)	105(48.8)	0.824
Single, not in relationship	29(50.9)	28(49.1)
Single, in relationship	48(47.5)	53(52.5)
Religion
Catholic	69(52.3)	63(47.4)	0.242
Protestant	115(50.4)	113(49.6)
Muslim	4(28.6)	10(71.4)
Location of the school
Rural	125(48.6)	132(51.4)	0.024
Urban	54(46.2)	63(53.8)	0.024
Welfare category
Category A	20(46.5)	23(53.5)	0.277
Category B	74(54.4)	62(45.6)
Category C	81(48.5)	86(51.5)
Category D	10(40.0)	15(60.0)
Category E	3(100)	0(0)
Live at boarding school
Yes	170(50.6)	166(49.4)	0.418
No	18(47.4)	20(52.8)	0.418
Level of study
A Level	69(50)	69(50.0)	0.937
O Level	119(50.4)	117(49.6)	0.937

Age group and location of the school were statistically associated with the use a contraceptive or an HIV Preventive method (p-value < 0.05).

Table 7

Cross tabulation of attitude toward contraceptive methods and use of contraceptives or HIV preventive methods.
Variables			P-value
Use of contraception or HIV preventive measures
Use of contraception will make sex unpleasable	Yes n(%)	No n(%)	0.567
Strongly disagree	48(44.6)	59((55.1)
Disagree	31(58.5)	22(41.5)
Neutral	50(48.5)	53(51.5
Agree	32(48.5)	34(51.5)
Strongly agree	24(53.5)	21(46.7)
Use of contraception will increase safety from unwanted pregnancy, HIV, and AIDS
Strongly disagree	9(64.3)	5(35.7)	0.264
Disagree	9(69.2)	4(30.8)
Neutral	14(66.7)	7(33.3)
Agree	47(52.2)	43(47.8)
Strongly agree	111(47.0	125(53.0)
Opinion on telling friends of contraceptive use
Strongly disagree	8(57.1)	6(42.9)	0.762
Disagree	7(53.8)	6(46.2)
Neutral	15(71.4)	6(28.6)
Agree	45(100.0)	45(100.0)
Strongly agree	110(46.6)	126(53.4)
Personal judgment of contraceptive use being what is best for self
Strongly disagree	9(56.2)	7(43.8)	0.047
Disagree	18(60.0)	12(40.0)
Neutral	14(48.3)	44(51.2)
Agree	42(48.8)	111(52.1)
Strongly agree	102(47.9)	111(52.1)
Telling boyfriend/girlfriend to use contraception being the right thing
Strongly disagree	11(55.0)	9 (45.0)	0.936
Disagree	9(42.9)	12(57.1)
Neutral	14(46.7)	16(53.3)
Agree	60(50.8)	58(49.2)
Strongly agree	94(50.8)	91(49.2)
Telling boyfriend/girlfriend of contraceptive use makes relationship stronger
Strongly disagree	38(56.7)	29(43.3)	0.182
Disagree	37(51.4)	35(48.6)
Neutral	37(59.7)	25(40.3)
Agree	35(45.5)	42(54.5)
Strongly agree	41(42.7)	55(57.3)
Delay to have sex until older
Delaying sex increases safety from HIV/AIDS			0.105
Strongly disagree	7(77.8)	2(22.2)
Disagree	6(54.5)	5(45.5)
Neutral	9(64.3)	5(35.7)
Agree	25(38.5)	40(61.5)
Strongly agree	141(51.3)	134(48.7)
One’s judgment on waiting
Strongly disagree	1(50.0)	1(50.0)	0.046
Disagree	1(16.7)	5(83.3)
Neutral	5(27.8)	13(72.2)
Agree	47(46.1)	55(53.9)
Strongly agree	134(54.5)	112(45.5)
Personal decision to delay having sex until the older age
Strongly disagree	5(45.5)	6(54.5)	0.702
Disagree	3(30.0)	7(70.0)
Neutral	11(55.0)	9(45.0)
Agree	37(48.1)	40(51.9)
Strongly agree	132(51.6)	124(48.4)
One’s judgment toward boyfriend
Strongly disagree	7(58.3)	5(41.7)	0.333
Disagree	5(45.5)	6(54.5)
Neutral	12(48.0)	13(52.0)
Agree	38(41.3)	554(58.7)
Strongly agree	132(51.6)	108(46.2)
One’s judgment toward girlfriend
Strongly disagree	12(60.0)	8(40.0)	0.321
Disagree	11(34.4)	21(65.6)
Neutral	19(57.6)	14(42.4)
Agree	63(50.8)	61(49.2)
Strongly agree	83(50.3)	82(49.7)

Results of cross tabulation of attitude toward contraceptive methods and use of contraception or an HIV preventive method showed that the statements “I’ll be doing what is best for me if I use condoms every time I have sex” and “If I tell my friends that I’m going to wait until I’m older to have sex, I know I’ll be doing the right thing” were statically associated with the outcome (p-value < 0.05).

Table 8

Cross tabulation of sexual reproductive history and use of contraceptives or HIV preventive methods.
Variables			P-value
Use of contraceptive methods or HIV preventive measures
Have had sexual intercourse	Yes n(%)	No n(%)	0.211
Yes	27(58.7)	19(41.3)
No	159(48.5)	169(51.5)
Age when first had sex
10–14	7(50.0)	7(50.0)	0.281
15–17	10(66.5)	5(33.5)
18–20	11(73.0)	6(27)
Frequency of sexual intercourse
1 time/week	8(33.3)	16(66.7)	0.295
2 times/week	4(75.0)	2(25.0)
3 times/week	0(0.0)	1(100.0)
Frequency of condom use during sexual intercourse
Rarely	7(87.5)	1(12.5)	0.865
Frequently	9(75.0)	3(25.0)
Never	7(35.0)	13(65.0)
Sometimes	5(83.3)	1(16.7)
Sexually active currently
Yes	155(50.7)	93(51.4)	0.605
No	33(49.3)	93(48.2)	0.605
Knowledge of contraception
Yes	155(50.7)	151(49.3)	0.021
No	33(49.3)	34(50.7)	0.021
Source of information about contraceptive/HIV preventive measures
Friends	34(50.7)	33(49.3)	0.369
Parents	47(54.0)	40(46.0)
Mass media	43(47.7)	47(52.3)
Healthcare facility	17(48.5)	18(51.5)
Youth center	32(48.4)	34(51.5)
Web pages	13(44.8)	16(55.2)
Contraceptive methods according to respondents
Pills, injections, or intrauterine device	23(57.5)	40(42.5)	0.263
Condom	59(48.3)	63(51.3)
Abstinence	7(47.5)	63(52.5)
Don’t know	2(100.0)	0(0.0%)

Knowing about contraception was statistically associated with the use of contraception or an HIV preventive method (p-value < 0.05)

Table 9

Results from multiple logistic regression.
Variables	OR	95%CI	P-value
Age group
13–15 (Ref.)
16–17	0.776	0.574–1.952	0.561
18–20	2.276	1.674–5.052	0.031
Location of the school
Rural (Ref)
Urban	2.733	1.061–4.316	0.047
Using condoms every time one has sex is best.
Strongly disagree (Ref.)
Disagree	0.649	1.246–1.653	0.134
Neutral	1.611	0.894–3.453	0.212
Agree	1.524	0.731–3.242	0.316
Strongly agree	2.611	1.472–6.777	0.023
Friends’ opinions: Waiting until one is older to have sex is best.
Strongly disagree (Ref.)
Disagree	0.739	1.457–1.463	0.634
Neutral	1.112	0.494–2.413	0.862
Agree	0.434	0.121–1.422	0.236
Strongly agree	0.511	0.352–0.817	0.033
Knowledge of what contraception is
No (Ref.)
Yes	2.096	1.650–5.883	0.021

Independent variables that showed significant associations with the dependent variable were included in multiple logistic regression analyses to identify their independent effects on the use of contraceptives or HIV preventive methods. The results indicated that participants aged 18–20 were more than twice as likely to use contraception or HIV preventive methods compared to those aged 13–15 (OR = 2.276, p-value = 0.031, 95% CI = 1.674–5.052). Participants who reported that their schools were located in urban areas were also more than twice as likely to use contraception or HIV preventive methods compared to those whose schools were in rural areas (OR = 2.733, p-value = 0.047, 95% CI = 1.061–4.316).

Additionally, respondents who strongly agreed that using condoms every time they have sex is the best choice for them were more than twice as likely to use contraceptive or HIV preventive methods compared to those who strongly disagreed (OR = 2.611, p-value = 0.023, 95% CI = 1.472–6.777). Conversely, participants who strongly agreed that telling their friends they will wait until they are older to have sex is the right thing to do had a 48.9% reduction in the odds of using contraception or HIV preventive methods compared to those who strongly disagreed (OR = 0.511, p-value = 0.033, 95% CI = 0.352–0.817). Finally, those who knew what contraception is were twice as likely to use contraception or HIV preventive methods compared to those who did not know (OR = 2.096, p-value = 0.021, 95% CI = 1.650–5.883).

Previous behavior and use of condoms or other contraceptive methods

According to this study, only 46 participants (12.3%) reported having had sexual intercourse, of which 37 (81.7%) engaged in risky sex, and only 9 (18.3%) of them frequently used condoms. This risk factor may be explained by cultural factors, where females are often unable to negotiate for safe sexual practices such as condom use, putting them at risk of pregnancy.¹⁸ Although 181 participants (48.4%) identified as being sexually active, only 63 (16.8%) were knowledgeable about contraception. This finding is consistent with a study conducted in Cameroon, which indicated that few adolescent girls knew how and where to access forms of contraception other than condoms.¹⁹ Only 133 respondents (35.6%) considered healthcare facilities as their source of information about contraception or HIV preventive measures. This is similar to findings by Kawuki et al., which showed that stigma regarding premarital sex creates barriers for sexually active adolescents in accessing contraceptive services.¹⁹

The primary source of information about contraception and HIV preventive measures cited by 90 participants (24%) was healthcare facilities. When asked to choose a method of contraception, 12% selected intrauterine devices, 37% chose condoms, and 83.4% preferred abstinence. This is similar to a nationwide study conducted by Kawuki et al. on the use of modern contraceptives by sexually active adolescent girls in Rwanda, where condoms were among the most commonly used options.²⁰ It is also consistent with Schwandt et al., who argued that Rwandans believe youth should not have sex before marriage.²¹ This aligns with the findings of Mugnier, where respondents appreciated the cultural value of virginity among girls.²² Furthermore, most prevention programs in Rwanda focus on "Abstinence and Proper Condom Use."²³

Determinants of the intention of contraception use

In response to our research question, two theoretical variables make them possible to predict the intention of young Rwandans in our targeted population to use condoms: 1) attitude toward the behavior, and 2) individual characteristics as an external factor to the framework.

Perceived norms

Subjective norms are the factors that most significantly explain the intention to use condoms in our sample. Our sample participants are motivated to conform to the expectations of influential referents. This finding aligns with studies conducted in African contexts, where subjective norms were identified as the strongest predictors of condom use. According to Yeboah et al. and Benefo, this dominant role of perceived norms may be due partly to the more collectivist nature of African societies, in contrast to the more individualistic decision-making processes in Europe and North America.^23,24

These results are consistent with a study conducted in Rwanda, which indicated that friends or peers are the most frequently consulted category by adolescents.²⁵ In this study, perceived norms showed that 146 participants (39.0%) strongly agreed that informing their boyfriend of their intention to use condoms every time they have sex would be acceptable. This finding is in line with Taylor et al., who noted that variations in overall beliefs accounted for between 34% and 56% of the variances reported in attitudes, subjective norms, and perceived behavioral control.²⁶

Attitude toward the behavior

Attitudes toward delayed sexual intercourse were measured, with the majority strongly agreeing (236 or 63.1%) that they would be safe from unwanted pregnancy, HIV, and AIDS if they used condoms every time they had sex. A study conducted in Ethiopia also revealed a positive attitude (83.6%) toward condom use.²⁷ The delay in having sex, the use of contraceptives and HIV preventive methods, as well as waiting until adulthood, were statistically significant (p-value < 0.015). This aligns with Rijsdijk et al., which found that the intention to delay sexual intercourse positively correlated with beliefs about HIV (r = 0.09; p-value < 0.01) and attitudes toward delayed sexual intercourse (r = 0.36; p < 0.01).²⁸ Additionally, Fisher et al. established that intentions to practice HIV preventive behaviors are formed by individuals who have positive attitudes toward preventive acts and perceive social support for these behaviors.²⁹

Contrarily, Sander et al. found that attitudes, subjective norms, and self-efficacy were weakly to moderately correlated with condom use at baseline and follow-up in a study conducted in Dar es Salaam.³⁰ However, in two other sites, attitudes significantly predicted intentions in using condoms (Cape Town: B = 0.32; Mankweng: B = 0.24). This is consistent with Manloe et al., which discovered that adolescents who had taken a virginity pledge had decreased odds of contraceptive use or consistency.³¹

The American Academy of Pediatrics recommends discussing abstinence with adolescents as the most effective way to prevent genital STIs, HIV infection, and unintended pregnancy.³² The New Times suggested that Rwandan youths and adolescents prioritize abstinence, but for sexually active youths and adults, especially those engaging in transactional sex, protected sex should be prioritized to avoid sexually transmitted diseases, including HIV, and unplanned pregnancies.³³ According to Friendly, being abstinent is one of the best decisions one can make, as it is the only method that avoids pregnancy, STIs, and HIV/AIDS 100% of the time.³⁴

Individual characteristics

Among the individual features of the participants in this study, the age group of 18–20-years-old (p-value = 0.041), urban location of the school (p-value = 0.037), year of study (p-value = 0.032), and knowledge about contraception (p-value = 0.011) were statistically associated with the use of contraception and HIV preventive methods (p-value < 0.05).

With regard to the group of women aged 18–20, it is obviously clear that, as one advances in age, decision-making for the free choice of a certain contraceptive practice or product becomes stronger. Similarly, for the knowledge of a practice and product, we are more likely to use or practice something that we know well and with which we are familiar. Therefore, knowing the contraceptive methods and the preventive measures against HIV infection is an advantage for its subsequent use. As for urban living, Aubert noted that there is a striking contrast between the capital Kigali, where more than half of Rwanda's urban population lives, and rural areas, with considerable differences in standards of living and economic productivity.³⁶ Rwanda seems to be evolving in two different worlds: a highly modern one in its capital with a growing segment of relatively well-paid urban professionals, and a traditional world in the countryside with a large population of people who are close to the poverty line but are managing to avoid severe economic hardship.

This is in line with the study done by Kawuki et al. that confirmed modern contraceptive use was positively associated with older age.²⁰ In that study, girls who were 19 years were 10.28% (95%CI: 1.34–78.71) times more likely to use modern contraceptives than 15-year-olds, while those with tertiary education were 6.98% (95%CI: 1.08–45.07) times more likely to use contraceptives compared to their counterparts with no education.²⁰ Those residing in Kigali were 75% less likely to use contraceptives compared to their fellows in the Southern region (AOR = 0.28, 95%CI: 0.099–0.802).²⁰

Framework and results

The results of this study show that two constructs of the TPB model are significant predictors of the intention to use contraceptive methods and HIV preventive measures. According to Ajzen, perceived norms explain a larger portion of the variance in intention compared to the other constructs.³⁶ Additionally, attitude—another construct—directly influences intention. In the case of perceived norms, other studies have reached similar conclusions.^2,37,38 Furthermore, as predicted by this theory, external variables (such as age, living area, and knowledge about contraceptive methods and HIV preventive measures) influence behavioral intentions through their effects on the model's components.³⁹

Strengths and weaknesses of the study

Using a theoretical framework accepted by researchers and other theoreticians in the field of health underscores the robustness of this study. Indeed, according to Godin et al., recent meta-analyses have demonstrated that the TPB is highly effective in predicting and explaining various health-related behaviors.⁴⁰ In Rwanda, very few studies have utilized a universally recognized theoretical framework.

The approach adopted for developing the measuring instrument is clear, as the various stages recommended by the model have been adhered to. A pilot study conducted demonstrated excellent metrological qualities. Additionally, the use of a predictive correlational approach to explain the relationships between variables and verify theoretical models is appropriate.⁴¹ Random sampling helped to avoid possible biases.

Regarding limitations, the sample size is a constraint for this study. Moreover, this study may be influenced by social desirability bias, which is inherent in any research involving a behavioral component and in studies with questions that are sensitive and touch upon intimate subjects.^42,43

Practical implications

In the short term, the results of this study will be shared with local authorities of the Rwamagana District, school principals, and representatives of parents from respective schools. This information could help authorities better shape policies regarding the prevention of unwanted pregnancies and HIV/AIDS among teens.

The Ministry of Health of Rwanda, as part of its strategic plan (2018–2024), has tasked the Rwanda Biomedical Center with leading the implementation of the National Family Planning and Adolescent Sexual and Reproductive Health strategic plan.⁴⁵ This initiative involves coordination with internal entities, other ministries, development partners, and civil society. One aspect of this effort includes the creation of one-stop centers in various administrative sectors where young people can access information on family planning and sexual and reproductive health. Through these one-stop centers, youth in rural areas can be sensitized and educated about contraceptive methods and preventive measures against HIV infection. Additionally, it would be beneficial to introduce a sexual and reproductive health course into the curriculum for both rural and urban schools, emphasizing contraceptive methods and HIV preventive measures.

Various advertising campaigns could target parents and health professionals to promote preventive measures. Rwandan parents need to understand the importance of becoming resourceful figures for their children and should not shy away from discussing healthy sexuality. Adolescents should be educated on the importance of seeking information from healthcare facilities. Health professionals should be made aware of the significant role they play in the lives of young people and understand the crucial role they can fill in prevention efforts.

Further studies

A similar study with a larger sample size is essential to generalize these findings and examine potential differences based on gender and education levels among adolescents. It is crucial to conduct research involving young adolescents, boys, and men, as they play a significant role in combating unwanted pregnancies and preventing the sexual transmission of HIV. Additionally, future studies could employ different frameworks. While the two variables discussed effectively explain the variance in the intention to use contraceptive methods and HIV preventive measures among Rwamagana teens, it is likely that other predictive factors remain unexplored. Moreover, further research aimed at developing programs for parents and future healthcare workers is essential.

This study aimed to identify the psychosocial determinants underlying the intention to use contraceptive methods and preventive measures again HIV infection among teenage Rwandan female students in secondary schools in Rwamagana District. Ajzen's TPB served as a framework for this study. Statistical analyses showed that attitudes were a key predictor of the intention to use contraceptive methods and HIV preventive measures. Three external variables, namely the age and location of participants and their knowledge of contraceptive methods and HIV preventive measures were also statistically significant.

Intervention strategies aimed at increasing contraceptive methods and HIV preventive measures have been suggested based on these findings. They target three levels: parents, healthcare professionals, and local authorities, and these strategies all have the same goal: increasing sexual health. A series of research based on predictive theories and behavior change is essential to better understand the phenomenon as it appears to have not been studied widely yet in Rwanda. In conclusion, we believe this research has successfully identified the factors influencing the intention to use contraceptive methods and HIV preventive measures among Rwandan students. The findings will contribute to guiding discussions on essential interventions for this demographic.

AFSRH: adolescent-friendly sexual and reproductive health

CI: Confidence Interval.

HIV/AIDS: Human Infection Virus Acquired Immunity Deficiency Syndrome.

OR: Odds Ratio

STIs: Sexually transmitted infections

TPB: Theory of Planned Behavior

THP: Teen Health Project

Ethics approval and consent to participate

The study received ethical clearance (Approval notice: 326/CMHS IRB/2022) from the College of Medicine and Health Sciences (CMHS) of the Directorate of Research and Innovation of CMHS Intuitional Board prior to initiation. Informed and written consent were obtained from the respondents before they were interviewed.

Consent for publication

Not applicable.

Data availability.

The datasets used and analyzed during this study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Funding

The authors received no funding for this study from CIRTH.

Author contributions

Faculties from School of Nursing and Midwifery of University of Rwanda conceptualized and designed the study. They led the data collection process, analyzed the data, screened the data and critically revised the analysis and discussed the results. They also drafted the manuscript themselves. All authors read and approved the final manuscript for publication. All authors confirm that they had full access to all the data in the study and accept responsibility for submission for publication. The corresponding author attests that all authors meet authorship criteria and that no criteria were omitted.

Acknowledgments

This research was funded with support from Center for International Reproductive Health Training at University of Michigan (CIRHT-UM). 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 details

¹ School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda

² School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda

³ Center for International Reproductive Health Training, University of Michigan, Ann Arbor, MI, USA.

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Social Welfare or Ubudehe in Kinyarwanda refers to the long-standing Rwandan practice and culture of collective action and mutual support to solve problems within a community. The focus of traditional Ubudehe is mostly on cultivation.

No competing interests reported.

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You are reading this latest preprint version

Determinants Underlying Teenager’s Accessibility to Contraceptive Methods and HIV Preventive Measures in Rwamagana District, Rwanda

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Abstract

Figures

Introduction

Definition of concepts

Specific method aims

Framework

Research methodology

Multistage sampling

Measurements

Intentions

Perceived behavioral control

Perceived norms

Attitude

Validity and reliability

Ethics consideration

Data collection and management

Analysis

Findings

1. Sociodemographic information of participants

2. Components of TPB

2.1. Perceived norms

2.2. Attitude

3. Individual characteristics regarding students’ sexual and reproductive history

Discussion

Previous behavior and use of condoms or other contraceptive methods

Determinants of the intention of contraception use

Perceived norms

Attitude toward the behavior

Individual characteristics

Framework and results

Strengths and weaknesses of the study

Practical implications

Further studies

Conclusion

List of acronyms and abbreviations

Declarations

References

Footnotes

Additional Declarations

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