Uptake of Modern Contraception Among Youths (15-24) at Community Level in Busia District, Uganda

UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (15-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA

BY:

SUSAN BABIRYE KAYONGO

MakSPH-CDC FELLOW

FEBUARY 2013

UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (15-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA

BY:

SUSAN BABIRYE KAYONGO

B.MASS COMM.; MPHL

MakSPH-CDC FELLOW

MakSPH-CDC FELLOWSHIP PROGRAM

FEBUARY 2013 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 ...... 1 1.0 INTRODUCTION AND BACKGROUND...... 2 1.1 Introduction ...... 2 1.2 Background ...... 3 1.3 Statement of the Problem...... 6 1.4 Significance of the Study ...... 6 2.0 LITERATURE REVIEW ...... 8 2.1Background Information on Youths’ Sexuality and Contraception ...... 8 2.1.1 Sexual Behaviors of Youths in Sub-Saharan Africa ...... 8 2.1.2 Contraception among Youths in Uganda ...... 9 2.2 Factors Affecting Contraceptive Use among Young People ...... 11 2.2.1 Individual Factors ...... 11 2.2.2 Reproductive Health Service Factors ...... 13 2.3 Research Questions and Objectives...... 17 2.3.1 Research Questions...... 17 2.3.2 General Objective ...... 17 2.3.3. Specific Objectives ...... 17 2.4 Conceptual Framework...... 18 3.0 METHODOLOGY ...... 19 3.1 Study Design ...... 19 3.2 Study Area and Population ...... 19 3.2.1 Study Area ...... 19 3.2.3 Sample Size ...... 20 3.2.4 Sampling Procedure ...... 20

3.2.5 Study Variables ...... 23 3.3 Data Collection Procedures ...... 23 3.3.1 Tools ...... 24 3.4 Data Management, Quality Control and Analysis ...... 25 3.4.1 Data Management ...... 25 3.4.3 Data Analysis ...... 26 3.5 Ethical Considerations ...... 27 4.0 RESULTS ...... 29 4.1 Introduction ...... 29 4.2 Demographic Characteristics of Respondents ...... 29 4.2.1 Socio-demographic Characteristics of Respondents ...... 29 4.2.2 Sexual and Reproductive Behaviors and Experiences of Respondents ...... 30 4.3 Use and Preferences of Contraceptives among Respondents ...... 32 4.3.1 Contraceptive Prevalence ...... 32 4.3.3 Modern Contraception Preferences of Respondents ...... 33 4.3.4 Contraceptive Use Behaviors and Practices among Respondents ...... 34 4.3.5 Source of Contraceptives at Community Level ...... 36 4.4 Factors that Influence Uptake of Modern Contraceptives among Respondents ...... 37 4.4.1 Logistic Regression Predicting the Likelihood of Modern Contraceptive Use ...... 37 4.4.2 Logistic Regression Predicting the Likelihood of Condom Use ...... 38 4.4.3 Logistic Regression Predicting the Likelihood of Use of Depo-Provera ...... 39 4.5. Young People’s Perceptions towards Receiving Contraceptives from the Different Service Providers at Community Level ...... 40 4.5.1 Perceptions of Youths towards Contraceptive Uptake by Youths ...... 41 4.5.2 Perceptions of Youths towards Availability and Variability of Contraceptive Services ...... 41 4.5.3 Perceptions of Youths towards the Information Given to Clients ...... 43 4.5.4 Perceptions of Youths towards Provider’s Technical Competences ...... 44 4.5.5 Perceptions of Youths towards Provider’s Interpersonal Relations ...... 45 4.5.6 Perceptions of Youths towards the Availability of Mechanisms for Continuity of Contraceptive Use ...... 45 4.5.6 Perceptions of Youths towards Constellation of Services ...... 46

4.6. Community level provider’s perspectives on provision of contraceptives to youths ...... 47 4.6.1 Non Attitudinal Factors...... 47 4.6.2 Attitude Related Factors ...... 51 5.0 DISCUSSION ...... 57 5.1 Introduction ...... 57 5.2 Discussion ...... 57 6.0 CONCLUSIONS AND RECOMMENDATIONS...... 61 6.1 Conclusion ...... 61 6.2 Public Health Implications & Recommendations ...... 61 REFERENCES ...... 63

iii

LIST OF TABLES AND FIGURES

TABLE 1: Socio-demographic characteristics of respondents……………….………...30

TABLE 2: Sexual and reproductive behaviors and experiences of respondents by contraceptive uptake…………………………………………..…………………...……31

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……………………………..………………………...37

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………….…………………………...39

FIGURE 1: 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

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 (15-24) at community level in Busia district, Uganda. ……pages © Babirye Susan Kayongo, 2013

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

ACKNOWLEDGEMENTS

I would like to begin by expressing my appreciation first to the FHI360-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 360 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.

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

ACRONYMS AND ABBREVIATIONS

CBD Community-Based Distribution

CBDI Community-Based Distribution of Injectable contraception

CDC Center for Disease Control and Prevention

CRTU Contraceptive and Reproductive Health Technologies Research and Utilization

FP Family Planning

H/C Health Center

IDI In-depth Interviews

MOH Ministry of Health

PROGRESS Program Research for Strengthening Services

SC Save the Children

SRH Sexual Reproductive Health

VHT Village Health Team

VHTM Village Health Team Member

UNCST Uganda National Council for Science and Technology

viii

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 15 and 24

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 15-24 years within the project area of CBDFP in Busia district, Uganda. METHODS: This was a descriptive cross sectional study conducted between May and August, 2012. 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 13% (43/323) of all the survey respondents were married and below 20 years. A big proportion (62%) of respondents reported using modern contraception and majority of the users (56%) sought contraceptives from government health facilities. Only 14% from CBDs. Condom was the most used method at 71.7%, followed by Depo-Provera at 31.8%. Sex and marital status were found to significantly influence condom use [sex: OR =2.74; 95% CI = 1.61-4.66; marital status OR =2.27; 95% CI = 1.11-4.65] whereas, age and marital status had a statistical significance with use of Depo-Provera [age: OR=0.43, 95%CI= 0.21-0.87; marital status: OR=0.13, 95%CI= 0.06-0.31, 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.

1.0 INTRODUCTION AND BACKGROUND

1.1 Introduction

Worldwide there over 1.8 billion young people and nearly 90 percent of whom live in developing countries [1]. The age-range 15 to 24 is a period when most people begin to actively explore their sexuality. Globally, most people become sexually active before their 20th birthday [2] and in sub-Saharan Africa, 75 percent of young women report having had sex by age 20 [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 10 births and one in 10 abortions worldwide and one in six births in developing countries is to women aged between 15-19 years. Each day half a million of young people are infected with a sexually transmitted disease [6]. Nearly 12 million young people are living with HIV/AIDS; and more than 7,000 young people become infected with HIV every day [7]. While about 16 million adolescent girls aged 15-19 give birth each year, accounting for more than 10 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 [9,10]. 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 [11]. 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

women in the general population than increasing the provision of Nevirapine for HIV- positive mothers within antenatal care [12].

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 [13]. Despite those facts, contraceptive prevalence rate in Sub Saharan Africa has generally remained low at only 21 percent and adolescent girls being the age group with the lowest contraceptive prevalence rate [14].

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 [15]. 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.

1.2 Background Uganda has the youngest age structure in the world; with 77 percent of its population under the age of 30 and about 20 percent aged 15-24 years [16]. In Uganda, young people typically become sexually active, marry, and bear children early in life. By 15 years of age, 11 percent of adolescents have initiated sex and by 18 years 64 percent of young

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 435/100,000 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 [17]. Birth intervals remain short, and Ugandan women have more than three children by their late 20s [16]. Nearly half of the 1.4 million annual pregnancies occurring in Uganda are unwanted [18]. Unintended pregnancies have been linked to unsafe abortions that constitute nearly one third of maternal deaths among young people in Uganda [19].

Uganda has a liberal family planning policy that allows access to contraceptive services to every sexually active individual and couples irrespective of age [20], 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 10- 20 percent of young people report ever using modern contraceptives apart from condoms [21] 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 15–19 and 20–24 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 80 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.

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 80 districts in Uganda at some point in time [26].

Several organizations, including the Ministry of Health (MOH) and about 10 Non- Governmental Organizations (NGOs), have or still provide family planning services through CBD programs in Uganda. FHI360, an international organization with an office in Uganda, runs one of the largest CBD program, established in 2006. To date, FHI360 has supported 15 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, 30, 31]. 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 2008. The CBD programme is run by the district health team with support from the USAID through FHI360. The aim of the study was to

assess the uptake of contraceptives among youths aged 15-24 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.

1.3 Statement of the Problem Uptake of contraceptives among youths in Uganda is still low at10 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 15-24 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.

1.4 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.

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.

2.0 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.

2.1Background Information on Youths‟ Sexuality and Contraception

2.1.1 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 15 years of age, 11 percent of Ugandan adolescents have initiated sex and by 18 years 64 percent of young people have had their first sexual encounter [33]. In Kenya, 62 percent of never married male students age 11 to 17 years and 30 percent of females had already had sexual intercourse. The median age at first intercourse was 14 for males and 17 for females [34]. Whereas in South Africa, a national survey of contraceptive use and pregnancy among women age 15-25 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 50 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].

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 12–14 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 1 in 10 very young adolescents have had some sort of intimate sexual activity, ranging between 7–12% [36].

2.1.2 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 [17]. But only eight percent of married women aged 15-19 and sixteen percent of those aged 20-24 use modern contraceptive methods. Five percent of married youth aged 15-24 rely on traditional methods. Furthermore, 63 percent of sexually active unmarried women 15-19 years and 43 percent of sexually active unmarried women 20-24 years are not using any contraceptive method at all [17,20]. Condom use is low in Uganda; only two percent among married women

aged 15-24 use condoms. It is worth noting that contraceptive use is two times lower in rural compared to urban areas [17]. 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 15-24 want to space or limit childbirth but are not using contraceptives [18].

2.1.2.1 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 15–19 who reported having sex with more than one partner in the past three months said they had used a condom [40]. According to Bankole’s study, condom use was highest among male adolescents in Ghana (68 percent) and lowest in Malawi (50 percent). On the contrary, data from Demographic and Health Surveys [41] show that oral contraceptives or injectables are the most popular hormonal method among 15 to 24 year-olds in the developing world, with rates of use exceeding 20 percent in some countries. Far fewer young women use implants, with rates of use below 1 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 15 to 19 years than among young adults ages 20 to 24.

2.1.2.2 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 15 to 19 are more likely than older women to stop using contraception within a year of starting [43]. Another, a study of about 1,000 women using oral contraceptives, injectables, or the intrauterine device

(IUD) in Benin found that the one-year cumulative probability of discontinuing any of the methods was about 74 percent for women younger than 20, compared with 43 percent for women ages 20 to 30 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, socio- economic, 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.

2.2.1 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 (1997) 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

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. 31 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 [50].

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 [51]. 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].

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.

2.2.2 Reproductive Health Service Factors

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 [60]. In an assessment of nine countries, the percentage of women who said that they would rather be using a different method ranged from 11 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 [61]. 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].

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 40 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 1,570 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

of client counseling, lack of privacy for counseling, and high clinic caseloads were major weaknesses in the province's family planning program [70].

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 [71]. 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" [70]. If clients do not receive their preferred

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 [70,73]. 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

2.3.1 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?

2.3.2 General Objective 1. To assess the uptake of modern contraceptives and the factors which influence uptake among youths (15-24 years) within the project area of CBDFP in Busia district, Uganda. in Busia district, Uganda.

2.3.3. Specific Objectives 1. 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.

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 Acceptance of o Demographic factors i.e. age, gender, education, marital status Contraceptives etc. o Socio-cultural factors i.e. decision making powers, desire for children etc. Contrace o Socio-economic factors like cost of ptive

services, transport Use among

youths

Continuation of Reproductive health service factors o Choice of care i.e. Public health contraception 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 18

3.0 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.

3.1 Study Design This was a descriptive cross sectional study conducted between May to August 2012 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

3.2.1 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 FHI360. FHI360 is an international not for profit organization. In Uganda FHI 360’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 187 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 15 districts currently supported by FHI360 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 18 H/C IIs.

With nine sub counties, 537 villages and 47,886 households, Busia district currently has a population of 281, 500 people compared to the 225000 people estimated in the 2002

population and housing census of Uganda. In 2010-2011, Busia district had 56,782 women in the reproductive age with 14,055 pregnancies and 13633 births. Busia district contraceptive prevalence rate is still low at 37 percent and lower for the age group 15-24, [76] even though its slightly higher than the national contraceptive prevalence rate.

3.2.2 Study Population and Sample The study population comprised of sexually active youths between ages 15-24 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 15-24 years from the six randomly selected villages of Buhehe Sub County. The samples were youths (15-24) from the six study villages of Buhehe who reported being sexually active and volunteered to participate in the study.

3.2.3 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, 30% is an average for the 15-19 and 20-24 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= t2xp(1-p) m2

Where: n = required sample size t = confidence level at 95% (standard value of 1.96) p = estimated contraceptive prevalence rate for youths (15-24) at national level m = margin of error at 5% (standard value of 0.05)

3.2.4 Sampling Procedure Multi-level sampling was used in this study. Different sampling techniques were used as explained below;

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 FHI360.

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 1 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

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 15-24 years and residents of the six study villages were included in the study. Similarly, sexually active unmarried youths who were between 18-24 years and residents of the six study villages were also considered for this study. In addition, even sexually active unmarried youths (15 and 18 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 15 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.

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.

3.2.5 Study Variables In this study, the dependent (outcome) variable was contraceptive use among youths 15- 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 12 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

respective communities, and each interview lasted 45 to 60 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.

3.3.1 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 face- to-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.

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

3.4.1 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 3.5.1.

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.

3.4.2 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.

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.

3.4.3 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

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 14 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 18 years old and not married, consent was sought from their parents. Participants below 18 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 18 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 18 years had to give their written consent before the research assistants

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 15 and 18 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 18 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.

4.0 RESULTS

4.1 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

4.2.1 Socio-demographic Characteristics of Respondents

A total of 323 sexually active young people participated in the survey. The mean age of the respondents was 19.5 years, age range was 15-24, and 51% of the respondents were between ages 15-19 while 49% between 20-24 years. Female respondents constituted the biggest proportion (62%) of the study respondents while 13% (43/323) of the study respondents were married and below 20 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.

TABLE 1: Socio-demographic Characteristics of Respondents

Variable Frequency Percent (N=323)

Age (%) 15-19 165 51% 20-24 158 49% Sex Female 199 62% Male 124 38% Marital status Single 166 51% Married 157 49% Religion Christianity 316 97.8% Islam 3 0.9% Others 4 1.2% Education level None 12 3.7% Primary school 190 58.8% Secondary school 113 35% Tertiary education 8 2.5% Tribe Samia 305 94.4% Basoga 3 0.9% Itesot 4 1.2% Japadhola 1 0.3% Others 10 3.1% Occupation No other work 1 0.3% Farmer 158 48.9% Student 112 34.7% Vendor/Shop owner 9 2.8% Teacher 2 0.6% House wife 25 7.7% Others 16 5.0%

4.2.2 Sexual and Reproductive Behaviors and Experiences of Respondents

Findings on sexual and reproductive behaviors and experiences showed that 16% 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%)

had given birth, with 12.5% 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 Contraceptive uptake (Freq) [n=323(n %)] Yes [n=201] No [n=122]

No. of sexual partners 1 271 (83.9%) 167 (83%) 104 (85.2%) 2 and above 52 (16.1%) 34 (16.9%) 18 (14.7%) Knowledge of HIV status Yes 237 (73.3%) 154 (76.6%) 83 (68%) No 86 (26.7%) 47 (23.3%) 39 (31.9%) Knowledge of partners‟ HIV status Yes 151 (46.8%) 101(50.2%) 50 (40.9%) No 172 (53.2%) 99 (49.2%) 73 (59.8%) STI protection Nothing 68 (21.1%) 2 (0.9%) 66 (54.0%) Condom use 139 (43%) 139 (69.1) - Faithfulness 113(35%) 59 (29.3%) 54 (44.2%) Others 3 (0.9%) 1 (0.4%) 2 (1.6%) No. of children 0 153 (47.3%) 93 (46.2%) 60 (49.1%) 1-2 130 (40.2%) 82 (40.7%) 48 (39.3%) 3-5 40 (12.5%) 26 (12.9%) 14 (11.4%) Fertility desires ≤ 4 children 244 (75.5%) 149 (74.1%) 95 (77.8%) ≥ 5children 79 (24.4%) 52 (25.8%) 27 (22.1%) No. of siblings ≤ 4 siblings 78 (24.1%) 48 (23.8%) 30 (24.5%) ≥ 5 siblings 245 (75.8%) 153 (76.1%) 92 (75.4%)

4.3 Use and Preferences of Contraceptives among Respondents

4.3.1 Contraceptive Prevalence

Of all the 323 sexually active youths (15-24) 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 122 respondents who were not currently using modern contraceptives, reported ever used any method in their life time. Nonuse of modern contraceptive was common among non- married females below 20 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=201) No (n=122) Age 15-19 165 (51.0%) 97(48.2%) 68(55.7%) 20-24 158 (49%) 104(51.7%) 54(44.2%) Sex Female 199 (61.6%) 122(60.6%) 77(63.1%) Male 124 (38.3%) 79(39.3%) 45(36.8%)

Marital status Single 166 (51.3%) 104(51.7%) 62(50.8%) Married 157 (48.6%) 97(48.2%) 60(49.1%) Schooling status In-school 112 (34.6%) 68(33.8%) 44(36%) Out of school 89 (44.2%) 133(66.1%) 78(63.9%)

4.3.3 Modern Contraception Preferences of Respondents

Condoms were found to be the most preferred contraceptive method at 71.7%, followed by Depo-provera at 31.8% 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 18/201 (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 1: 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 18.8% liked a method which

was less expensive and 17% 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 3

4.3.4 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 15% had used any method consistently for 2 years and above. This finding matched with the FGD findings were one respondent remarked:

“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

Condom use: Furthermore, findings on condom use behaviors and practices also revealed improper and inconsistent use of condoms among youths. Only 10% of condom users reported using condoms correctly and consistently (used condoms every time and round of sex) while 19% 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

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 12% 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

4.3.5 Source of Contraceptives at Community Level

Out of the 201 youths who reported using contraceptives, 56 percent obtained the services from government health facilities, 22 percent obtained from drug shops, while 14 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

4.4 Factors that Influence Uptake of Modern Contraceptives among Respondents

Various factors were identified and considered in the study. These included factors like respondent’s age, sex, marital status, schooling status, number of children, siblings and fertility desires.

4.4.1 Logistic Regression Predicting the Likelihood of Modern Contraceptive Use

The logistic regression (Table 4) revealed that none of the variables (i.e., age, sex, marital status, schooling status, number of children, siblings and fertility desires) were significantly associated with use of modern contraceptive among the study respondents (P>0.05). However, although marital status was not statistically significant in the model, after adjusting for other factors, being married increased the probability of using modern contraceptives by nearly 50% compared to those who reported not being married [OR=1.45:95%CI =0.62-1.77]. Other factors such as being below 20 years, having no children and the desire for having ≥5 children were less likely to influence use of modern contraceptives [OR=0.70:95%CI= 0.40-1.21, OR=0.88:95%CI= 0.31-2.46 and OR=0.88:95%CI= 0.71-2.96].

TABLE 4: Unadjusted and Adjusted Odds Ratios for the Factors Influencing Modern Contraception among Respondents

Independent Use of modern Unadjusted Adjusted variables contraceptive

Yes No OR CI-95% OR CI-95% Age 20-24 years 104 54 1 1 15-19 years 97 68 0.74 (0.47-1.16) 0.70 (0.40-1.21) Sex Female 122 77 1 1 Male 79 45 1.11 (0.70-1.76) 1.05 (0.62-1.77) Marital status Married 97 60 1 1 Single 104 62 1.03 (0.66-1.63) 1.45 (0.71-2.96) Schooling status Out of 133 78 1 1 In-school 68 (0.61-2.17) school 44 1.10 (0.69-1.77) 1.15 No. of children 3-5 26 14 1 1 1-2 82 48 0.92 (0.44-1.93) 1.02 (0.44-2.33) 0 93 60 0.83 (0.40-1.72) 0.88 (0.31-2.46) No. of siblings ≥ 5 siblings 153 92 1 1 ≤ 4 siblings 48 30 0.96 (0.57-1.62) 0.96 (0.56-1.63) Fertility ≤ 4 children 149 95 1 desires 1 ≥ 5children 51 28 0.87 (0.51-1.48) 0.88 (0.49-1.57)

4.4.2 Logistic Regression Predicting the Likelihood of Condom Use The logistic regression model analysis after adjusting for other factors, results indicated statistically significant factors to use of condoms to be; sex and marital status. It was nearly three (3) times more likely that male respondents reported use of condoms [OR =2.74; 95% CI = 1.61-4.66] than their female counterparts. Similarly, it was two (2) times more likely that respondents who were not married would report use of condoms [OR =2.27; 95% CI = 1.11-4.65] than married respondents.

Although not having children was not statistically significant in the model at 5% level, it increased the probability of using condoms by 25% [OR =1.25; 95% CI = 0.63-2.48]. On the other hand, factors like number of siblings and schooling status were less likely to influence use of condoms [OR=0.97: 95%CI= 0.55-1.70, and OR=0.88: 95%CI= 0.46- 1.69].

TABLE 5: Unadjusted and Adjusted Odds Ratios for the Factors Influencing Use of Condoms among Respondents

Independent Condom Unadjusted Adjusted variables Use

Yes No OR CI-95% OR CI-95% Age 20-24 years 59 99 1 1 15-19 years 84 81 1.74 (1.12-2.71)** 1.01 (0.57-1.78) Sex Female 65 134 1 1 Male 78 46 3.50 (2.19- 2.74 (1.61-4.66)*** Marital status 5.59)*** Married 44 113 1 1 Single 99 67 3.80 (2.38- 2.27 (1.11-4.65)* Schooling status 6.04)*** Out of school 77 134 1 1 In-school 66 46 0.40 (0.25- 0.88 (0.46-1.69) Parenthood 0.64)*** With a child/ren 53 117 1 1 Without a child 90 63 3.15 (1.98- 1.25 (0.63-2.48) No. of siblings 4.98)*** ≥ 5 siblings 138 36 1 1 ≤ 4 siblings 42 107 1.10 (0.66-1.84) 0.97 (0.55-1.70) Fertility desires ≤ 4 children 129 114 1 1 ≥ 5children 51 28 1.61 (0.95-2.72) 1.25 (0.63-3.04)

4.4.3 Logistic Regression Predicting the Likelihood of Use of Depo-Provera

When the same predictors (age, marital status, number of siblings and fertility desires) were compared to use of Depo-Provera, significant associations were seen. The logistic

regression (Table 6) revealed that age group and marital status of the respondents had a statistical significance with use of Depo-Provera. Being in the age group 15-19 was associated with less use of Depo-Provera [OR=0.43: 95%CI= 0.21-0.87] compared to being in age group 20-24 years old. Similarly, not being married was associated with less use of Depo-Provera [OR=0.13: 95%CI= 0.06-0.31] compared to being married. Other factors like having less than five siblings and desire to have children or more, although not found statistically significant, lessened the probability of using Depo-Provera [OR=0.70:95%CI= 0.34-1.47, and OR=0.55: 95%CI= 0.29-1.06].

TABLE 6: Unadjusted Odds Ratios for the Factors Influencing Use of Depo- Provera among Respondents

Independent Use of Depo- Unadjusted Adjusted variables Provera

Yes No OR CI-95% OR CI-95% Age 20-24 years 50 104 1 1 15-19 years 14 151 0.20 (0.10-0.38)*** 0.43 (0.21-0.87)** Marital status Married 56 101 1 1 Single 8 158 0.91 0.04-0.20)*** 0.1 (0.06-0.31)*** No. of siblings 3 ≥ 5 siblings 51 194 1 1 ≤ 4 siblings 13 65 0.76 (0.39-1.49) 0.70 (0.34-1.47) Fertility desires ≤ 4 children 40 203 1 1 ≥ 5children 24 55 0.45 (0.25-0.81)** 0.55 (0.29-1.06)

4.5. Young People‟s Perceptions towards Receiving Contraceptives from the Different Service Providers at Community Level

In all the focus group discussions, respondents discussed the quality of care they receive when they access contraceptives at the different providers at community level. Some of the elements of quality of care discussed included; choice of methods (availability and variability); information given to clients; technical competence of providers;

interpersonal relations; follow- up and continuity mechanisms; and the appropriate constellation of services.

4.5.1 Perceptions of Youths towards Contraceptive Uptake by Youths Before discussing issues of quality of care, respondents were first asked about their opinion on the use of modern contraceptive method by youths between the ages 15-24 years. The discussion on use of contraceptives indicated that some youths were in support of contraceptive use while others thought not all youths should use contraceptives. Some youths perceived that contraceptives were meant for the married and those with children:

“It’s good for both married and unmarried to use contraceptives because for the married, it helps us avoid having poorly spaced children while for non-married and those still at school, it helps them prevent unwanted pregnancies thereby staying longer at school and finishing their studies”. Female participant, FGD 4

“I think contraceptives are meant for people above 18 years old. If contraception is started at an early age, you may fail to produce in future”. Female participant, FGD 3

“If you’re not married, it is not good because contraceptives might affect your ovaries and fail to reproduce in future but if you’re married, it’s okay”. Male participant, FGD 1

On the other hand, some youths believed that there were some contraceptive methods which shouldn’t be used by the unmarried youths and those who hadn’t reproduced:

“I think it depends on a method chosen because there those methods that affect young girls and those which do not. Condoms are fit for those who have never given birth or married unlike Depo and pills”. Male participant, FGD 2

4.5.2 Perceptions of Youths towards Availability and Variability of Contraceptive Services All youths who participated in the FGDs reported that the availability and variability of contraceptive services from all providers wasn’t assured. They however acknowledged that among all the contraceptive distribution alternatives at community level, at least

government health centers had a variety of methods and they were available most of the time. Participants mentioned that CBDs and drug shops mainly dispensed pills, Depo and condoms and sometimes were faced with stock outs:

“It is at least the government health centers that have many methods available and in big quantities”. Male respondent, FGD 3

“Community based distributors stock few pills and when you go there and find when pills are finished, they just inject you”. Female respondent, FGD 2

Further discussion on the availability of services revealed that even where methods are available, youths reported missing out on the services sometimes because the providers are too busy to attend to them or not willing to dispense to youths. Youths also mentioned that sometimes they’re denied services if they do not have money:

“I have ever gone for condoms and I was told they’re dispensed to only those who’re 18 years old and above”. Male participant, FGD 2

“I was 14 years old and I was denied the injectable. They told me that young people don’t use family planning”. Female participant, FGD 4

“If you’re in a hurry, you rather go to a drug shop because at the Bunyadeti (government health center) the client turn up is big and for CBDs you have to wait for them to finish their domestic chores before you’re served”. Male participant, FGD 3

Further probing highlighted a major complaint of both participants in the two focus group discussions of current users of contraceptives and this was the waiting time at the health facilities. This was in response to what the discussants disliked about service delivery points that they visit. A large number of clients estimated that they spend about two to three hours waiting for services and a few participants noted that on several occasions, they had left without the service even when the methods are available at the facility.

4.5.3 Perceptions of Youths towards the Information Given to Clients Participants reported receiving detailed counseling from government providers and community-based distributors. They pointed out that most of the drug shop operators did not give any counseling to their clients. Those who had ever sought services from CBDs reported receiving quality time, detailed counseling on all contraceptive methods. Participants also mentioned that CBDs responded to their concerns before dispensing any method:

“I use condoms and I get them from Lumino H/C and whenever I go there, they educate me on condom use”. Male respondent, FGD 1

“Our CBD educate us on the benefits and side effects of Depo before she injects us. Even when you revisit her, she asks you if you’ve experienced any side effects and she again explains to you more about side effects”. Female participant, FGD 3

“For me at the shop I just pay and am given my condoms and I go away”. Male participant, FGD 2

Further probing on information given to clients by providers, revealed gaps such as lack of privacy during counseling, counseling on only the available methods and less information given to continuing users:

“The drug shop is small. It is just a single room and there is no privacy. The drug shop operator talks to you even in presence of other customers”. Male participant, FGD 4

“When I went for immunization at Bunyadeti (government health center), they taught us about family planning in a group and there after those who wanted contraceptives were each given a method of their choice”. Female participant, FGD 4

“When you go to a CBD for the first time, she takes a lot of time, counsels you on family planning and allows you to even go back home and think through it,

discuss with your partner and go back for a method you’ve decided to use. But the consequence visits you spend little time at the CBD compared to the first time. Within five minutes she is through with injecting and you’re back to your work”. Female client, FGD 2 4.5.4 Perceptions of Youths towards Provider‟s Technical Competences Views from all FGDs participants showed that youths trusted the technical competency of contraceptive providers at government facilities. They mentioned that they were trained, experienced and offered detailed counseling in addition to managing side effects:

“I want to go where they have the skill to manage side effects that’s why I go to Buhehe H/C were there skilled staffs”. Female participant, FGD 3

“I prefer government health centers because there they test blood and they can easily chose for me a method that best suits my body and therefore have no side effects”. Female participant, FGD 4

However, on the other hand, in all the FGDs it was unanimous that drug shop operators were not trained, lacked experience and that why they gave wrong and expired methods in addition to not giving detailed information on contraceptives to their clients. When asked what they wanted to see changing with the current contraceptive service delivery, one respondent remarked:

“The government should train drug shop operators because they lack the skills to treat people. They give wrong drugs and sometimes sell to us expired drugs. They should also be often inspected”. Male participant, FGD 2

A few of the participants especially those who had ever sought CBDs services pointed out that community based distributors were more knowledgeable and skilled at providing condoms, pills and injectables. Participants mentioned that CBDs counseled them on all methods including benefits and side effects of these particular methods:

“When I went to our VHT (CBD), he brought out his books and taught me about contraceptives methods as I saw them in the pictures”. Male participant, FGD 3

“He (CBD) gives the injection very well. I have never got any problem on the hand where he injects me. In fact he injects far better than those providers at the clinics because for him he is always at Bunyadeti (government health center) where he learns from”. Female participant, FGD 4 4.5.5 Perceptions of Youths towards Provider‟s Interpersonal Relations Discussions on provider-client relations revealed that, community based distributors of contraceptives and drug shop operators had good customer care towards their clients. Participant mentioned that these two providers were welcoming and sociable compared to the health care workers at government facilities. Majority of respondents in all FGDs reported that health care workers at government facilities were unkind and always attend to them hurriedly. One participant noted:

“CBDs treat us well because sometimes they’re the ones who mobilize us for Depo”. Female participant, FGD 2

“They treat us well although sometimes you reach there and they tell you that they are busy. Mostly during lunch time, but if they’re not busy, they give the client a lot of time and explain issues in details”. Female respondent, FGD 3

“…… they’re not friendly, when you reach at the health center you wait from the waiting area for you turn. For condoms, the health care provider appears and talks to everybody who wants condoms in a group and then hurriedly gives you the condoms. But you go to the drug shop and see how well they will care for you because they know you have taken for them money”. Male respondent, FGD 2

4.5.6 Perceptions of Youths towards the Availability of Mechanisms for Continuity of Contraceptive Use Although mentioned in varying degrees of emphasis across FGDs, mechanisms that aimed at ensuring continuity in contraceptive use were hinted on during the discussions. Participants mentioned mechanisms such as provision of client cards to remind clients on return dates, follow up visits by CBDs and referrals linkages to each other (the providers). Participants explained that CBDs referred them to the government health

centers for contraceptives in case they lacked commodities. They also mentioned that in situations of side effects, CBDs asked their clients to go to a government health facility and talk to a midwife. Although on a small scale, some participants mentioned that some drug shop operators referred them to a government hospital for methods not provided at a drug shop. Further probing, showed that CBDs followed up on their clients more often than the other providers. One female participant remarked:

“….She (CBD) gave me a client card on which she writes my return dates. I often check on this card to recall my due date for the next injection (Depo). I have never missed my return dates, I have always returned on that particular day. Sometimes she (CBD) passes by my home and reminds me about my due date”. Female participant, FGD 3

“One time I went back for another injection (Depo) and he did not have the drugs. He wrote for me a form and told me to go the government health center for service. I didn’t go that day but went and received my injection two days later”. Female participant, FGD 2

“……during antenatal, the mid (midwife) told us about the distributors of contraceptives within our communities and that’s how I got to know them. But I have never gone for their services”. Female participant, FGD 1

4.5.6 Perceptions of Youths towards Constellation of Services The issue of constellation of services came out as an important issue during the group discussions especially among the two FGDs of current users of contraceptives. One participant remarked:

“My first time to pick condoms was when I went for circumcision at Masafu Hospital. After circumcision, I was given condoms for protection. The second and third time, I went to Lumino H/C III because I wanted to test for HIV addition to picking condoms”. Male participant, FGD 3

In all the FGDs it was enormous that government health centers had a collection of services under the same roof compared to the other providers. Participants mentioned

going for services such as HIV counseling and testing, immunization and circumcision in addition to contraceptives: “I go to the Masafu because it’s the biggest hospital in our sub county and I can get whatever I want there”. Female respondent, FGD 4

4.6. Community level provider‟s perspectives on provision of contraceptives to youths

4.6.1 Non Attitudinal Factors

4.6.1.1 Existence of Guidelines Providers were first asked about the family planning guidelines and in response to this question, many were not certain as to whether family planning guidelines were in place or not. A few providers, who believed that family planning guidelines were in existence, did not know what the guidelines said on use of contraceptives by youth between the ages 15-24 years:

“I don’t think there guidelines in place. All I know is that if you deny someone a method; he/she will take away the money to somewhere else where he will be given what he wants”. Drug shop operator 1

“No. There are no guidelines. But I think the guidelines are there because they always teach us that before we dispense any method, we first interview the client to assess eligibility”. CBD 3

“……..they always tell us that if a young girl like of 15 years starts say, injectables and uses it for long like till she completes university, they say it might affect her hormones and she fails to produce. So, there we say it will cost her future if she fails to get children”. Midwife 1

Providers were further asked whether there were contraceptive methods prohibited from youths by the guidelines. Almost all providers interviewed were not sure as to whether there were methods prohibited from or allowed to be used to the youths. On the other hand, one midwife mentioned a Norplant, male and female sterilization as methods not permitted for youths:

”I am not sure about that, but what I know is that a provider cannot refer a youth who has never delivered for tubaligation or vasectomy”. CBD 1

“For a Norplant, we are not supposed to give them to youths who have not yet given birth or those still in school because it’s a long term method for five years and it might affect their hormones. And then according to the guidelines for male and female sterilization, they are not meant for youth who haven’t had children”. Midwife 2

4.6.1.2 Perceptions of Providers towards the Existence of Demand for Contraceptives among Youths Overall, providers believed that there was demand for contraceptives among the age group 15-24 years although some said that the turn up of youths for contraceptive services was just catching up due to the mobilization being done by community based providers: “Yes the demand for contraceptives among the youths is now there. Comparing when we had just started distribution of contraceptives in the community and now, there is certainly a big improvement. Now days many youths are turn up for services” CBD 2

”The demand for contraceptives is quite high. Many youths come and ask for Depo-provera, pills an even coil and even if I try to advise them on condom use, they are inflexible. There is also of sexual activities within this age group and many males come for condoms”. Midwife 2

“Yes the demand is there but for me I do not sell contraceptives to youths who have never given birth or those who are still at school. I always refer them to government health centers”. Drug shop operator 2

Even those providers, who thought otherwise on the issue of demand for contraceptives among youths, pointed out the high cases of teenage pregnancies in their community, which highlighted the need for contraceptives among youths in the community:

“The demand for contraceptives among youths is very low. In fact many young people in our community get pregnant at an early age”. Drug shop operator 1

Further probing on what influenced demand for contraceptives among youths (15-24) revealed a range of factors in favor and also against use of contraceptives. Among factors that prompted young people to use contraceptives mentioned by the providers included; burden of looking after a big family, fear of consequences of unwanted pregnancies, perceived benefits of contraceptives, contraceptive knowledge, and parental influence. On the other hand, providers mentioned factors like misconceptions and fears, lack of partner’s support and health service barriers to be limiting youths from using modern contraception. Providers reported that youths especially those without children believed that contraceptives interfered with fertility, and they were frightened to use something that could harm their ability to reproduce:

“Youths always ask us whether it is true that pills accumulate in the stomach leading to surgical operations and failure to reproduce”. CBD 1

4.6.1.3 Perceptions of Providers towards Accessibility of Contraceptives to Youths When asked whether contraceptive services were accessible to youths (15-24) in terms of the cost of services and availability of contraceptives, the providers stated those contraceptive methods that were accessible to the youths. Condoms, oral contraceptive pills and Depo-Provera were the methods mainly provided by all providers. Providers mentioned that for methods they did not dispense, they referred their clients to hospitals where the methods were dispensed. Of note among providers is that they all mentioned that most of the time they were available to provide contraceptives and except at night:

“……we have condoms, pills and Depo and all these methods can be offered to youths. Even if a 15 year old came, I would first go through my checklist and to find out whether she doesn’t have any health conditions that might lead to complications and if she’s okay, I will give it to her”. Midwife 2

“I stock only condoms and that is what I dispense to youths”. Drug Shop Operator 1

“I dispense only three methods (condoms, pills and Depo) and it’s because I was trained to distribute only those methods. The other methods require medical persons who are more skilled than us. So when we get clients who want the other methods, we refer them to the government health center where they can be attended to by skilled workers”. CBD 3

Further discussions on the availability of contraceptive services showed that providers were faced with frequent stock outs of contraceptives. By the time of this research, CBDs and government healthcare providers reported a stock out of Depo-Provera that had lasted for three months (April, May and June). The government health care providers further reported that the contraceptives delivered to them by the National Medical Stores (NMS) were few and yet they had to share with the CBDs. On the other hand, Drug shop operators mentioned that they stocked every time stock was finished:

“……. right now we are in a crisis since April we don’t have Depo. Although pills and condoms are available, our Depo clients are affected. They don’t accept to change and use the available methods and anyway it’s their right to decide. As a CBD am challenged as all my clients who were supposed receive Depo in April, May and June have not. I am worried if they are not careful they may become pregnant”. CBD 2

Further probing showed that even where contraceptives are available, certain situations such as cost services and provider bias limited access by youths. Some providers reported dispensing only condoms to youths and denying the other methods because they believed such methods were not suitable for young people or required medical tested from big health facilities:

“The methods (pills and Depo) that I have can be given to youths only after getting medical tests from the hospital and if the results show that her health can suit the method wanted, she will be given the service while there because me I’ll have referred her already…… if a youth says that she is married, I must prove that she consented with her partner by coming along with him”. Drug shop operator 2

“For condoms, I give like fifteen pieces per person…..it depends on how fast he uses them before coming back for more. If a person given fifteen condoms comes back in two days, there I will question him on how he used them”. CBD 2

Further still, some providers other than drug shops reported some form of monetary exchange from youth clients although they generally said that contraceptives were free of charge:

“One thing with our clients, when they see that you’ve served them for long, they appreciate. Especially when they see that they’re looking good and have not experienced side effects. One day on meeting at the T/C he/she may offer you a cup of tea as a sign of appreciation”. CBD 2

“……….I told her (client) the services are for free, something she couldn’t believe. That’s when she decided to give me 1000= saying this is your cup of tea and thanking me for the services”. CBD 1

“………….there was a time I received a client from Bulwenge and I inquired why she had to move a long distance to come here (at a government health center) yet there were CBDs in her own village. She (client) told me that the provider charged 500= which she didn’t have. I told her that CBD services are for free, but she insisted that if they didn’t have 500/= the CBD could not give them Depo”. Midwife 2

4.6.2 Attitude Related Factors

4.6.2.1 Perceptions of Providers towards Contraceptive Use by Youths Almost all providers interviewed were in support of youths using contraceptives although further probing revealed sentiments of bias. The providers were in agreement on the fact that contraceptives help youths to prevent sexually transmitted diseases such as HIV/AIDS and unwanted pregnancies thereby enabling them to stay longer in school. One drug shop operator was against use of contraceptives among youths. According to her, contraceptives make youths to live recklessly. On the other hand, some of the providers, who supported contraceptive use, had some reservations on proper usage:

“I do support use of contraceptives among youths only if it’s well used. I support it because it helps youths to stay in school longer and complete their studies but I believe youths need follow up for continuity”. CBD 2

“Sometimes youths come here for contraceptives and I counsel them very well but they end up stopping midway or misusing the method”. CBD 4

“Use of contraceptives among youth leads to promiscuity. That’s why I do not dispense to them any contraceptives except condoms. As a parent, children usually deceive us that they’re at school when it’s not the case. But if they don’t use contraceptives you can know the truth when they get pregnant”. Drug Shop Operator 2

Further probing on whether youths in school or the unmarried should use contraceptives revealed mixed feelings from the providers. Majority of the providers believed this group shouldn’t be seeking contraceptives but rather first finish their studies, avoid sexual relationships or be very careful in their relationships. Some providers said youth in school should be given condoms whereas others said they shouldn’t be given any contraceptives.

“I want youths in school to know that having sex without a condom will lead them into trouble. Let them come and pick condoms”. CBD 3

“I think we should reduce on dispensing contraceptives to youths in school because it’s just leading them into multiple sexual relations and yet they’re not ready to marry”. Midwife 1

“I think youths who’re still at school need to be very careful with whatever they’re doing. They should go for an HIV test and also use contraceptives”. Midwife 2

4.6.2.2 Perceptions of Providers towards Circumstances For or Against Contraceptive Use among Youths In general, providers believed that all sexually active youths needed to use contraceptives all the time especially if they were not ready to have children or for HIV protection.

“Before I got to know the benefits of contraceptives, I was against use of modern contraceptives among youths but now I strongly believe that sexually active youths should use contraceptives in order to be able to avoid pregnancies and stay longer in school”. CBD 2

“All circumstances that put a youth at a risk of getting unwanted pregnancy and HIV make it appropriate for them to use contraceptives”. CBD 1

“…….unless it’s for health related conditions otherwise I think youths can use all the methods we have anytime and some methods don’t even have side effects”. Midwife 2

However, some providers believed that contraceptive among youths should be restricted to certain emergency situations. For instance one provider said that youths should only be given emergency contraceptive pills and only in cases of rape or condom burst. In addition, side effects of contraceptives, inconsistent use and poor continuance were cited as reasons for not giving youths contraceptives (especially the unmarried and those still at school):

“Some methods like the hormonal several complications which I think are not good for a young person to start experiencing very early. They’re not even certain about their fertility and if they started using it early, it might even worsen the situation. That’s why you find some people taking a year trying to get a child after stopping the use of contraceptives”. CBD 4

“I think side effects like over bleeding make contraceptives inappropriate for young people”. Drug Shop Operator 1

4.6.2.3 Provider attitudes towards the relationship between Contraceptive use and the Sexual behaviors of youths Majority of the providers believed that contraceptives did not lead to promiscuity among youths. Instead they believed that it were the complacent attitude developed by youths using contraceptives that makes them worry less about HIV and therefore living recklessly:

“It (contraceptives) doesn’t increase promiscuity, but it makes them not to fear for their lives, they don’t care rest assured there is no pregnancy. These adolescents only fear pregnancy and nothing else”. Drug Shop Operator 2

“What I know about young girls is that if it’s her habit, she will have multiple partners whether she is using contraceptives or not. But if she is someone who takes advice even if she is using contraceptives, she will continue staying safe”. CBD 2

Some providers on the contrary believed that contraceptives lead to promiscuity among youths. One provider remarked: “It is not necessarily true although some young users become immoral. This is because they are sure that pregnancy will not occur”. Drug Shop Operator 1

“Somehow it (contraceptives) does lead to promiscuity, because a client knows she is safe. That’s why I always advise them to use condoms even when they’re using Depo such that they prevent HIV as well”. Midwife 2

4.6.2.4 Refusal to provide contraceptives to youths Four out the eight providers interviewed reported ever denied a youth contraceptives services during their service. And although the other four providers never reported having refused giving services to youths, some mentioned that at least they had referred them to other providers for contraceptives. Overall, those who reported never having refused giving services to youths were CBDs.

“On several occasions I have refused to dispense pills and Depo to youths. And they now know that I only give them condoms. If they want other methods other than condoms, always refer them to Masafu Hospital”. Drug Shop Operator 2

Yes, I have ever refused. When we were at school they told as that contraceptives are supposed to be started at least at 18 years. But I came to realize that there are many youths below 18 years who request for contraceptives and when you deny them the services, they end up with unwanted pregnancies. So I now feel it’s my

responsibility to give them contraceptives because if I do not, they end up into problems. Initially, I believed that if I gave young person contraceptives she would become promiscuous simply because she would not worry anymore about pregnancy”. Midwife 1

“When I had just graduated from school, I used not to give Depo to youths between 15-18 years and those still in school. I would advise them to use condoms. At college, we were taught not to give Depo-Provera to young people especially those still at school as it affected their hormones. They (tutors) said that if used longer, one would take long to conceive once married or they would completely fail to produce. But the on-job trainings (workshops) encouraged us to give even girls in school who would like to use because if denied, still they will go in for sex and end up with unwanted pregnancies and drop out of school”. Midwife 2

4.6.2.5 Perceptions of Providers towards the Norms Affecting Distribution of Contraceptives to Youths Religious and social norms were reported by the providers interviewed. The providers mentioned that some of their religious norms did not agree with use of modern contraceptives but instead supported use of natural contraception. This did not only apply to youths but to everybody and it was the Catholics who were affected. On the other hand, providers mentioned at although there was some slight change of attitudes by the community towards use of contraceptives, use among youths still had strong socio reservations: one provider said:

“My catholic belief supports only natural methods of contraception. But these other modern methods that I offer are not allowed. My husband doesn’t support them either because he a catholic catechist”. Drug Shop Operator 2

“At least the community and the church are starting to support are starting to appreciate the use of Family planning and through community activity some parents have started encouraging us to find time to talk to their children about family planning.”. Midwife 2

4.6.2.6 Suggested Interventions to Improve Uptake of Contraceptives among Youths The contraceptive providers identified a number of measures to improve uptake of contraceptives among youths at community level. These included; sensitization of youths on contraceptives by fellow youths, ensure privacy at distribution points and contraceptive distribution by youths. In addition, the providers noted the need to integrate contraceptive services with other services in-order to appeal more the youths. Ensuring client follow-up and consistent stocking of contraceptives were also mentioned by providers as measures to improve uptake of contraceptives among youths:

“I think youths need more sensitization but it should be done by fellow youths, same age groups and live examples of contraceptive users. Youths fear certain providers and require a lot of privacy, if a service is being provided by a fellow young person they feel more comfortable accessing it”. CBD 1

“Youths like to be followed up and regularly encouraged. They also want us (providers) to keep secret whatever they discuss they discuss with us. They value confidentiality a lot and if we maintained it, many will come to us”. CBD 3

“Giving them what they ask for is all they need”. Drug Shop Operator 1

“…. you hear them saying at other government health centers, condoms are put in a box and placed outside for us to pick by themselves but here…..This shows that some are shy to face us (providers). So, they want services but they don’t want in an open place”. Midwife 1

“They (youths) are happy to find the services they need available. They want to be served right away. When they fail to get the service sought, they get frustrated and some don’t have money to buy from drug shops. Also talking to them in a friendly manner makes them feel free with you in that even when you meet on the road, they comfortably ask you, musawo (provider), are our “things” (condoms) available?” Midwife 2

5.0 DISCUSSION 5.1 Introduction

In this chapter, the results of the study are discussed. Comparisons are made between previous related studies and the findings of this particular study.

5.2 Discussion

This study assessed the uptake and use of modern contraceptives and the factors that influence contraception among youths (15-24) at community level in Busia district, Uganda. The results showed that majority (62.2%) of the sexually active youths interviewed were currently using some form of modern contraceptives such as condoms, pills and Depo-Provera. This current contraceptive prevalence of any FP method is quite higher than the National prevalence of 10% among youths aged 15-24 years [77]. One possible reason for this high difference could be the difference in reference populations. The National prevalence was based on data from the general population of youths (15-24) not necessarily sexually active while the prevalence from this study was based on a sample of sexually active youths between the ages 15-24 years. The high rate of contraceptive use in this study could also be because of the availability multiple contraceptive providers in this community such as government health centers, drug shops and CBDs. Some providers such as CBDs have been found to improve accessibility, quality, acceptability, and impact [27, 28, 29 & 31]. This highlights the possibility of combined delivery models at community level increasing uptake of contraceptives among youths. Future research should examine this in order to inform programmers.

However, nearly 40% of sexually active youths reported not using any modern contraceptives and this should be of great public health concern. In Uganda where HIV prevalence in people aged 15 to 49 has increased from 6.4% in the 2004-05 to 7.3% in 2011 [78], high levels of sexual activity and unprotected sex are placing these youths at risk of HIV infection, as well as pregnancy. Research indicates that youths are at high risk of having high-risk sex, thereby increasing their risk for unintended pregnancy and sexually transmitted infections including HIV/Aids [4]. Again, research shows that contraceptive use reduces rates of teenage pregnancies. An analysis of data from the

National Survey of Family Growth (NSFG), found that 86 percent of the decline in teen pregnancy rates through 2002 occurred because teens were using contraceptives [79]. This study also showed that uptake of modern contraceptives was lower among unmarried females below 20 years. This could be because the youths themselves and the providers of contraceptives were a little reserved about use of contraceptives by the unmarried and in-school youths. Studies have demonstrated difficulties in satisfying contraceptive needs in communities where contraceptives are believed to be only for married people [80]. The results indicate that generalized contraceptive services for youths could not be a solution to the low up of contraceptives among youths. The implications of this is that family planning programs targeting youths should not aim at everybody but rather focus on specific subgroups because amongst youths, there are more vulnerable subgroups. Increasing use of contraceptives among youths may require messages and services tailored towards individual groups.

Furthermore, data from this study indicated that, sex and marital status of respondents were associated with using condoms while age and marital status increased the likelihood of using Depo-Provera. In particular, we note that males and those who reported being single were more likely to report using condoms compared to the female and married respondents. On the other hand, those who were between the ages 20-24 years and the married were more likely to report using Depo-Provera compared to those between the ages of 15-19 and the unmarried respondents. Similarly, a study in Kenya and Nigeria showed that condom use was more amongst men compared to women [81,82], the latter with a population of students in institutions of higher learning. This finding could explain the findings in a study amongst the Latino community that showed that females were at a high risk of unprotected sex compared to their male counterparts [83]. Again, studies carried out in Kenya, Ghana and Brazil [85,84,85] also indicated that condom use was less among married couples compared to those who were single. This draws more attention to fact that young people’s contraceptive needs and preferences differ by age group and marital status.

Related to the above, condoms were reported to be the main contraceptive method used among the study participants. This is similar to the findings of other studies where the

most commonly known, ever used, and currently used contraceptive was condom [86,87]. Further still, this study showed that youths used only short term contraceptives like condoms, contraceptive pills and Depo-Provera. This indicates knowledge gaps among youths, limited access to comprehensive contraceptive information as well as full range of contraceptive services. Another reason for use of only short term contraceptives could be that youths are at the onset of their reproduction and therefore believe use of long term methods like norplants is inappropriate. On the other hand, it could mean that young people are mainly interested in condoms and Depo-provera and therefore an opportunity for promoting condoms and Depo-provera use among youths since acceptability is already demonstrated.

The findings of this study further suggest that the quality of contraceptive services provided to youths is low. In their own perspective of the different aspects of quality of care at the alternative distribution points at community level, youths expressed gaps in the in existing services. This low quality of services could be indicative of the difficulties youths experience in receiving modern contraceptives and also reason for the low uptake of contraceptives among youths despite a conducive policy environment [20]. Evidence from various settings suggests that receiving good quality contraceptive services encourages acceptance or continuation of contraceptive use. One of the earliest of the studies, which highlighted the importance of some of the aspects of quality like choice and contraceptive continuation, was a panel study of 1,945 Indonesian women [88]. After adjustment for the effects of several variables, the analysis of this Indonesian study found that women who reported being given the method they desired were significantly more likely than other women to be using a contraceptive one year later. One possible explanation for the low quality highlighted in this study could be limited capacity of the contraceptive providers to appropriately give information and services in a manner and an environment that attract and sustain the interest of youths in utilizing modern contraception services. Previous research has also shown that interpersonal relations are related to contraceptive use [89]. This finding highlight the need for the Ministry of Health to develop a structured uniform training manual for all providers for consistence of contraceptive service delivery. Furthermore, the manual should carry a section of youths since their contraceptive needs a unique from the rest of potential contraceptive

users. Still on training, capacity building interventions should target private providers like drug shop operators since the study showed a wider gap in knowledge and skills of contraceptive delivery among this type of provider compared to others.

This study also explored the perceptions of different family planning providers on the provision of contraceptives to young people. The study showed a slight positive shift in the provider perceptions in favor of dispensing contraceptives to young people but still, there were a lot of concealed provider biases driving service delivery practices. For example, providers in this study revealed exclusionary practices based on age or marital status, as has been documented elsewhere in Africa [90,91]. Research using mystery clients in Nigeria showed that adolescents experienced negative and judgmental attitudes and were sometimes counseled on moral matters rather than contraceptive methods when trying to access family planning services[92]. Similarly, in our study providers universally reported counseling the young and unmarried on abstinence from sex rather than contraceptive methods when they sought contraceptive services. Another study in Uganda revealed that providers believed that contraceptives would cause infertility, thereby influencing provider restrictions and behaviours [93]. In the same manner, some providers in this study believed that if contraception was started too early or before childbirth would lead to delayed fertility or to the worst, infertility. The provider's health and safety concerns, especially regarding unmarried young people and those without children, resulted in hesitation in providing contraceptives. This finding highlight gaps in provider knowledge on contraception as well as the influence of providers’ personal beliefs on service provision.

This study was limited by the small sample size and the fact that we never conducted exit interview with clients and therefore these might have had an impact on the study results. However, the findings can provide insight into how contraceptive service delivery to young people can be improved in similar rural settings and should be interpreted in light of small sample size.

6.0 CONCLUSIONS AND RECOMMENDATIONS

6.1 Conclusion In conclusion, the study showed that a big proportion of sexually active youths were using any modern contraceptive. It also showed uneven availability of contraceptive supplies and limited information characterized the contraceptive services accessed by young people. In addition, the providers had negative attitudes towards dispensing contraceptives to the unmarried and in-school young people. Therefore, to improve contraceptive uptake among young people; availability of contraceptive choices should not be compromised; providers should be trained in how to serve young people; and dispensing contraceptives should be accompanied by adequate information.

6.2 Public Health Implications & Recommendations

This study highlights several program and policy implications. To begin with, the high rate of contraceptive use in a community with several contraceptive delivery models, could be indicative of the possibility of combined delivery models at community level increasing uptake of contraceptives among youths. Secondly, gaps in providers' knowledge and competence need to be addressed immediately in order to improve on how providers serve young people so as to meet the individual needs of different groups of young people. Furthermore, young people should be well informed about and have access to a variety of contraceptives. There is also need for family planning programmers to harmonize the existing family planning training materials for knowledge uniformity across providers. In addition, as a standard practice, all family planning training materials should have a section on young people just as it is with other vulnerable groups like people living with HIV/Aids. Still on capacity building, this study has shown a wider gap in knowledge and skills between DSOs and the rest of the providers in spite of young people having a positive perspective of their client relations. Although in Uganda, drug shops are not accredited to provide injectable contraceptives, the reality is that drug shops particularly in rural communities play an important role in providing contraceptive services and their potential to reach young people should not be overlooked. Therefore capacity building interventions are needed to target drug shop operators for the safety of

their clients. This should be followed by processes of revisiting Uganda's regulatory and policy environment on drug shop services, after all evidence shows that even Village Health Team members with limited training, can safely administer the injectable contraceptive [29, 30]. Lastly, health systems need to disseminate policy guidelines beyond facility based providers such that both public and private sectors providers are familiar with service delivery policy guidelines and thus quality and uniformity in service delivery.

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87. Orji E.O, Adegbenro C.A, Olalekan A.W: Prevalence of sexual activity and family planning use among undergraduates in South West Nigeria. Eur J Contracept Reprod Health Care. 2005; 10 (4):255-60. 88. Pariani S, Heer DM, Van Arsdo MD, Jr: Does choice make a difference to contraceptive use? Evidence from East Java. Studies in Family Planning, 1991, 22(6):384–390. 89. Kipp W, Chacko S, Laing L, Kabagambe G: Adolescent reproductive health in Uganda: issues related to access and quality of care. Int J Adolesc Med Health, 2007, 19: 383–393. 90. Adekunle AO, Arowojolu AO, Adedimeji AA: Adolescent contraception: survey of attitudes and practice of health professionals. Afr J Med Med Sci 2000;29:247–252. 91. Stanback J, Twum-Baah KA: Why do family planning providers restrict access to services? An examination in Ghana. Int Fam Plan Perspect 2001;27:37–41. 92. Olowu F: Quality and costs of family planning as elicited by an adolescent mystery client trial in Nigeria. Afr J Reprod Health 1998;2:49–60. 93. Nalwadda G, Mirembe F, Tumwesigye NM, Byamugisha J, Faxelid E: Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives. BMC Health Services Research 2011, 11:220

APPENDIX

APPENDIX 1: Consent form for youths above 18 years old

ASSESSING UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (15-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA. CONSENT FORM– SURVEY Title: Uptake and use of modern contraception among youths at community level in Busia district, Uganda. Sponsor: MakSPH-CDC Principal Investigator: Susan Babirye Kayongo, MakSPH CDC fellow at FHI360 Address: Makerere University School of Public Health/CDC Fellowship Program Plot 30 A, York Terrace, Kololo PO Box 7052 KAMPALA Phone: +256 414 533958 Mobile: +256 712 210002 Introduction Good morning/afternoon. My name is ______. We are working on a research study on the uptake and use of contraception among youths (15-24 years) at community level in Busia district, Uganda. Purpose of the study The purpose of this study is to assess the uptake and use of contraception among youths (15-24) at community level in Busia district, Uganda. Another purpose is to describe the factors that influence use of contraception among youths (15-24) at community level. In summary, the study will assess how many and why youths do or do not use contraceptives at community level. We want to be sure that you understand the purpose and your responsibilities in the research before you decide if you want to be in it. Please ask us to explain any words or information that you may not understand. Procedures The interview will last about between 45 and 60 minutes, but you may stop it at any time. I will ask you about your experiences using contraception and your perception towards

contraceptive services at community level. I will also ask you how you would like things to be done differently with contraceptive distribution at community level. Who will participate in the study? We expect to interview youths in the age group 15-24 years. We will also interview 12 youths who have ever sought contraception services at community level to better understand their experiences and feelings. Possible Risks We do not expect that you are at risk of any bad things happening to you by participating in this interview. I will ask you to respond honestly and to the best of your ability. There is no need to worry if you do not know the answer to a question. We will not discuss your responses with anyone. We will not report to anyone whether you decided to participate in an interview. Your participation in this interview will not affect your relationship. Possible Benefits The information that you share with us will help community-based family planning program managers find out the areas where improvements can be made so as to make CBD services more youth friendly. By participating in this interview, you will have a chance to share your experiences with decision makers. Confidentiality We will protect information you share with us to the best of our ability. We will not use your name in any reports. We will not tell anyone about your participation. We will not tell anyone the answers you give in this interview. Study Approval The Makarere University School of Public Health Research and Ethics Committee and the Uganda National Council of Science and Technology approved this study. Questions and rights as a participant If you have any questions about the research or your participation in the research, you may contact: Ms. Susan Babirye at 0712 210002. If you have any questions about your rights as a participant, you may contact: ………………, ……………………. at the Makarere University School of Public Health

Research and Ethics Committee, at ……………………………. [Contact information to be added.] Alternatives/Statement of voluntariness You are free to decide if you want to participate in this interview or not. If you decide not to participate, this will not be reported to anyone. If there is a question you do not feel comfortable answering, you can tell me so, and we can skip over it. You may also stop the interview at any time. Confirmation of your consent to participate Do you understand all I have just told you and do you agree to participate in this study? If you agree to participate in this study, you will need to sign this form. Yes No  STOP PARTICIPANT AGREEMENT

PARTICIPANT: I have read the study information / the study information has been read to me. I have been asked if I have any questions, and these have been answered to my satisfaction. I freely agree to participate. ______Name Signature or Thumb Print Date INTERVIEWER: I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual, and the individual has consented to participate. ______Name Signature Date

APPENDIX 2: Consent form for parents of youths below 18 years old

ASSESSING UPTAKE OF MODERN CONTRACEPTION AMONG YOUTHS (15-24) AT COMMUNITY LEVEL IN BUSIA DISTRICT, UGANDA. CONSENT FORM– SURVEY

Title: Uptake and use of modern contraception among youths at community level in Busia district, Uganda.

Sponsor: MakSPH-CDC

Principal Investigator: Susan Babirye Kayongo, MakSPH CDC fellow at FHI360

Address: Makerere University School of Public Health/CDC Fellowship Program

Plot 30 A, York Terrace, Kololo

PO Box 7052 KAMPALA

Phone: +256 414 533958

Mobile: +256 712 210002

Dear Parent/Guardian:

Introduction

Good morning/afternoon. My name is ______. We are working on a research study on the uptake and use of contraception among youths (15-24 years) at community level in Busia district, Uganda. We would like to involve your child in our study.

Purpose of the study

The purpose of this study is to assess the uptake and use of contraception among youths (15-24) at community level in Busia district, Uganda. Another purpose is to describe the factors that influence use of contraception among youths (15-24) at community level. In summary, the study will assess how many and why youths do or do not use

contraceptives at community level. We want to be sure that you understand the purpose and your responsibilities in the research before you decide if you want to be in it. Please ask us to explain any words or information that you may not understand.

Procedures

The interview will last about between 45 and 60 minutes, but participants may stop it at any time. The interview will be conducted within your compound. I will ask participants about their experiences using contraception and their perception towards contraceptive services at community level. I will also ask them how they would like things to be done differently with contraceptive distribution at community level.

Who will participate in the study?

We expect to interview youths in the age group 15-24 years -. We will also interview 12 youths who have ever sought contraception services at community level to better understand their experiences and feelings.

Possible Risks

We do not expect that your child is at risk of any bad things happening to him/her by participating in this interview. All information will remain completely confidential. No child will be identified by name. I will ask them to respond honestly and to the best of their ability. There is no need to worry if your child does not know the answer to some of the questions. We will not discuss your child’s responses with you or anyone. We will not report to anyone whether you declined your child to participate in an interview.

Possible Benefits

There will be no direct benefit to your child from participating in this study. However, the information that your child will share with us will help community-based family planning program managers find out the areas where improvements can be made so as to make CBD services more youth friendly. By your child participating in this interview, he/she will have a chance to share his/her experiences with decision makers.

Confidentiality

We will protect information your child will share with us to the best of our ability. We will not use your child’s name in any reports. We will not tell anyone about their participation. We will not tell you or anyone the answers your child will give in this interview.

Study Approval The Makarere University School of Public Health Research and Ethics Committee and the Uganda National Council of Science and Technology approved this study.

Questions and rights as a participant

If you have any questions about the research or your child’s participation in the research, you may contact: Ms. Susan Babirye at 0712 210002.

If you have any questions about your rights as a participant, you may contact: ……………………………………., ……………………………………… at the Makarere University School of Public Health Research and Ethics Committee, at …………………………………….. [Contact information to be added.]

Alternatives/Statement of voluntariness

You are free to decide if you want to participate in this interview or not. If you decide not to participate, this will not be reported to anyone. If there is a question you do not feel comfortable answering, you can tell me so, and we can skip over it. You may also stop the interview at any time.

Confirmation of your consent to participate

Do you understand all I have just told you and do you permit your child to participate in this study? If you agree to participate in this study, you will need to sign this form.

Yes

No  STOP

Should you or your child feel discomfort due to participation in this research, you should contact your health care provider.

PARENT OR GUARDIAN AGREEMENT

PARTICIPATION IN RESEARCH IS VOLUNTARY. I understand that I can choose not to have my child participate in this study, or to withdraw my child from participating at any time. I also understand that declining participation will not interfere with my child’s declined contraceptive services at community level.

I will discuss this research study with my child and explain the procedures that will take place.

I will be given a copy of this consent form to keep.

I give my consent to allow my child to participate:

Print Name

Signature of Parent/Guardian Date

APPENDIX 3: SURVEY QUESTIONNAIRE

UPTAKE & USE OF MODERN CONTRACEPTION AMONG YOUTHS AT COMMUNITY LEVEL IN BUSIA, UGANDA

Population survey

Participant ID number: [___|___|___]

Interviewer: ______

Interviewer number: [___|___]

Date of interview: [___|___] Day [___|___] Month [___|___|___|___] Year

Parish where interviews were conducted: ______

Parish code [___|___|___][___|___|___]

Village where interviews were conducted ______

Village code: [___|___|___][___|___|___]

Participation consent check

Respondent agreed to do the interview

[__] Yes

[__] No  END

INSTRUCTIONS

Interview each eligible, consenting youth individually and in private.

. All instructions to data collectors are in italics and bold. . Do not read the response options unless otherwise instructed. . Circle or record only one response to each question, unless otherwise instructed. . If a participant refuses to provide an answer to a question that has no “Refused to reply” option, do not circle any response option and hand write “Refused to reply”.

If any of the youth‟s responses leads to „END,‟ the youth is not eligible to participate. You should not proceed with the survey with this youth. Thank the youth for his/her time. Let

him/her know that he/she has not done anything wrong, but you would like to interview youths who may benefit most from this study.

CBD = Community Based Distributor

HC = Health Center

DS= Drug shop

FP = Family Planning

SECTION A: Socio demographic characteristics

To start, I would like to ask you some questions about yourself and your background.

NO. QUESTIONS CODING CATEGORY CODE SKIP

A01 [For interviewer] Record sex Female 1

Male 0

A02 How old are you? Enter age in years [___|___]

If less than 15 or above 24 years  END

A03 What religion do you practice? Christianity 1

Islam 2

Traditional 3

Others 4

A04 What tribe do you belong to? Samia 1

Basoga 2

Itesot 3

Japadhola 4

Others specify

A05 What is the highest level of school None 1 that you attended: primary, secondary, or higher? Primary 2 Secondary 3

Higher 4

A06 What is your occupation? No other work 0

Farmer 1

Only record one (primary) Student 2 occupation Vendor/Shop owner 3

Teacher 4

Housewife 5

Other (Specify) 6

A07 How many siblings do you have? Enter number of siblings below

A08 How many children do you have? Enter actual number of children below

A09 What is your desired number of Enter actual number of children and why? desired children below

Circle the number and record the reason

SECTION B: Sexuality and STIs including HIV

Thank you. Now I am going to ask you a few questions about your sexuality but please feel free to open up as confidentiality is highly assured.

NO. QUESTIONS CODING CATEGORY CODE SKIP

Single 1

B01 What is your marital status? Married 2

Separated or divorced 3

Widow or widower 4

B02 In the past 12 months, have you Yes 1 been in any sexual relationship? No 0

Reassure confidentiality If no  END

B03 How many sexual partners have you Enter the number of had in the past 12 months? partners below

PROBE for both spouse and casual partners

B04 Have you had an HIV test in the past Yes 1 12 months and got your results? No 0

B05 Do you know your partner’s or Yes 1 partners’ HIV status? No 0

B06 How do you protect yourself against Nothing 0 sexually transmitted infections including HIV/Aids? Use condoms 1 Faithfulness 2

Others (specify) 3

B07 How have been preventing No FP method 0  unwanted pregnancies in the past 12 C01 months? Modern contraceptives 1  Traditional FP methods 2 D01 Others specify 3

SECTION C: Non users of contraceptives

Thank you for sharing that information. Now let’s talk more about why you’re not using contraceptives despite being in a relationship.

NO. QUESTIONS CODING CATEGORY CODE SKIP

C01 Why are you not using Not currently sexually active 0 contraceptives? (If presently not using any) Currently pregnant 1 Desire to get pregnant 2

Preventing pregnancy by 3 other means 4 I feel I can’t get pregnant 5 Afraid of possible side effects 6 Contraceptives not easily accessed

Others reasons specify

C02 Have you ever used family planning Yes 1 before? No 0  C14

Ye No s C03 What contraceptive have you used? Condoms 0 1 Emergency contraceptive 0 pills 1 Circle „1‟ if mentioned and „0‟ if 0 not mentioned Contraceptive pills 1 0 Injectables 1 0 Implants 1 0 IUD 1 0 Natural family planning 1

Others specify

C04 What was the primary purpose of Prevent pregnancy 1 your uptake of contraceptives? Prevent STIs including HIV 2

Enhance sexual performance 3

Other reasons specify

C05 How were you protecting yourself Using condoms 1 against STIs while on non-dual protection methods? Trust my partner 2

Faithfulness 3

HIV testing 4

Ask this question only if condoms Others specify where not mentioned in C03

C06 For how long did you use the 1day 1 contraceptives mentioned above? 1 week 2

1 month 3

3 months 4

6 months 5

9 months 6

1 year 7

2 years and above

C07 Where did you access contraceptives Public health facility 1 from? Drug shop 2

Community based distributor 3 (CBD)

Others specify

C08 How long was the distance to the Enter the time mentioned by contraceptive distribution point the respondent below where you picked the method?

Estimate by time spend to the service provision point

C09 How exactly did you use 1 pill everyday 1 contraceptive pills? Prior to sexual intercourse 2

Once in a while 3 This applies to only users of pills I leave out the brown pills on 4 every cycle 5 Others specify

C10 How exactly did you use condoms? Every time I have sex 1

Every around of sex 2

This applies to only condoms users Every time and round of sex 3

First three months in a 4 relationship 5 Once in a while

Others specify

C11 How many injectable contraceptives Enter in number [___|___] did you received consistantly?

C12 What is your favorite contraceptive Condoms 1 method? Emergency contraceptive 2 pills 3 Contraceptive pills 4 Injectables 5 Circle the method Implants 6 IUD 7 Natural family planning

Others specify

C13 Why is the above your favorite Easy to use 1  contraceptive method? C16 Cheap 2

Long duration 3

Privacy 4

Less side effect 5

Others specify

C14 Do you know of Yes 1 contraceptives/family planning? No 0

Ye No s C15 Which contraceptives/family Condoms 0 planning methods do you know? 1 Emergency contraceptive 0 pills 1 0 Circle „1‟ if mentioned and „0‟ if Contraceptive pills 1 not mentioned 0 Injectables 1 0 Implants 1 0 IUD 1 0 Natural family planning 1

Others (specify)

C16 Which contraceptive provides Condoms 1 protection against both STIs and unwanted pregnancies? Emergency contraceptive 2 pills 3 Contraceptive pills 4 Injectables 5 Implants 6 IUD 7 Natural family planning

Others (specify)

C17 How did you learn about Friends/relatives 1 contraceptives/family planning? Mass media/radio 2

Hospital/health worker 3

CBD 4

Community outreach 5

Others (specify) You can tick more than one

C18 What are the benefits you think one Ye No can derive from family planning? s Control number of birth 0 1 Children spacing 0 You can tick more than one 1 Prevent unplanned/unwanted 0 pregnancy 1

Prevent sexually transmitted infection

Enhance sexual performance 0 1 No significant positive effect 0 Don’t know 1 0 1

C19 What don’t you dislike about Side effects 1 contraceptives? Regular refilling 2

Others specify

C19 Where are contraceptives obtained Record the service 1 in your community provision points i.e. gov‟t HC, Drug shop, CBD, 0 outreach & others  E01

SECTION D. Contraceptive uptake, use and preferences

Thank you for sharing that information. Now let’s talk more about your experiences using contraceptives.

NO. QUESTIONS CODING CATEGORY CODE SKIP

D01 Ye No s What contraceptive are you or have Condoms 0 you used in the past 12 months? 1 Emergency contraceptive 0 pills 1 0 Circle „1‟ if mentioned and „0‟ if Contraceptive pills 1 not mentioned 0 Injectables 1 0 Implants 1 0 IUD 1 0 Natural family planning 1

Others specify

D02 Why did you use more than one Dual protection contraceptives in the past 12 months? First method not available

Opted for long term method

Ask this question if a participant Side effects mentioned more than one method Others specify above?

D03 What is the primary purpose of your Prevent pregnancy 1 uptake of contraceptives? Prevent STIs including HIV 2

Enhance sexual performance 3

Other reasons specify

D04 How are you protecting yourself Using condoms 1 against STIs while on non-dual protection methods? Trust my partner 2

Faithfulness 3

HIV testing 4

Ask this question only if condoms Others specify where not mentioned in C03

D05 For how long have you used the 1day 1 contraceptives you’re currently using? 1 week 2 1 month 3

3 months 4

6 months 5

9 months 6

1 year 7

2 years and above

D06 Where did you access Public health facility 1 contraceptives from? Drug shop 2

Community based distributor 3 (CBD)

Others specify

D07 How long is the distance to the Enter the time mentioned by contraceptive distribution point the respondent below where you picked the method?

Estimate by time spent to the FP delivery point

D08 How exactly do you use 1 pill everyday 1 contraceptive pills? Prior to sexual intercourse 2

Once in a while 3 This applies to only users of pills I leave out the brown pills on 4 every cycle 5 Others specify

D09 How exactly do you use condoms? Every time I have sex 1

Every around of sex 2

This applies to only condoms users Every time and round of sex 3

First three months in a 4 relationship 5 Once in a while

Others specify

D10 How many injectable contraceptives Enter in number [___|___] have you received in the past 12 months?

D11 Have you discussed with your Yes 1 spouse/partner about the use of No 0 contraception at any time?

D12 Does your partner approve of use of Yes 1 contraceptives/family planning No 0 methods?

D13 Does your family in support of use Yes 1 of contraceptives/family planning No 0 methods?

D14 Has money ever hindered you from Yes 1 the use of family planning? No 0

D15 What is your favorite contraceptive Condoms 1 method? Emergency contraceptive 2 pills 3 Contraceptive pills 4 Injectables 5 Circle the method Implants 6 IUD 7 Natural family planning

Others specify

D16 Why is the above your favorite Easy to use 1 contraceptive method? Long duration 2

Privacy 3

Less side effect 4

Others specify

C17 Where did or do you access Public health facility 1 contraceptives from? Drug shop 2

Community based distributor 3 (CBD)

Others specify

D18 How did you learn about Friends/relatives 1 How contraceptives/family planning? did Mass media/radio 2 you learn Hospital/health worker 3 about CBD 0 contra ceptiv Community outreach es? Others (specify)

Ye No s D19 Which contraceptives/family Condoms 0 planning methods do you know? 1 Emergency contraceptive 0 pills 1 0 Circle „1‟ if mentioned and „0‟ if Contraceptive pills 1 not mentioned 0 Injectables 1 0 Implants 1 0 IUD 1 0 Natural family planning 1

Others (specify)

D20 Which contraceptive provides Condoms 1 protection against both STIs and unwanted pregnancies? Emergency contraceptive 2 pills 3 Contraceptive pills 4 Injectables 5 Implants 6 IUD 7 Natural family planning

Others (specify)

D21 What are the benefits you think one Ye No can derive from family planning? s Control number of birth 0 1 Children spacing 0 You can tick more than one 1 Prevent unplanned/unwanted 0 pregnancy 1

Prevent sexually transmitted infection

Enhance sexual performance 0 1 No significant positive effect 0 1 Don’t know 0 1

D22 What don’t you dislike about Record responses contraceptives?

D23 Where are contraceptives obtained Record the service in your community provision points i.e. gov‟t HC, Drug shop, CBD, outreach & others specify

SECTION E: Experiences and perceptions towards seeking and using contraceptives at community level

Thank you for sharing that information. Now let’s talk more about your experiences seeking and using contraceptives at community level.

NO. QUESTIONS CODING CATEGORY CODE SKIP

E01 Are you aware of community based Yes 1 distributors of contraceptives/family planning in your community? No 0

If NO  F01

E02 How did you learn about CBD of Friends/relatives 1 contraceptives/family planning? Mass media/radio 2

Hospital/health worker 3

CBD 4

Community outreach 5

Others (specify) You can tick more than one

E03 How close is the nearest CBD to Enter the time mentioned by you? participant

Estimate distance using time spent walking to a CBD

E04 What type of contraceptives services Yes No do they provide? FP counseling 1 0

Condoms 1 0

Emergency contraceptive 1 0 pills 1 0 Circle „1‟ if mentioned and „0‟ if Contraceptive pills not mentioned 1 0 Injectables 1 0 Implants 1 0 IUD 1 0 Natural family planning

Others (specify)

E05 Are CBD contraceptive services Yes 1 always available? No 0

Unsure 88

E06 Have you ever sought contraceptives Yes 1 from CBD? No 0

If NO  F21

E07 Was this the past 12 months? Yes 1

No 0

E08 How many times have you accessed Enter a number services from a CBD?

E09 What type of service did you seek? Yes No

FP counseling 1 0

Condoms 1 0

Circle „1‟ if mentioned and „0‟ if Pills 1 0 not mentioned Injectable 1 0

Emergency contraceptive 1 0 pills

Others (specify)

E10 Did you receive all the information Yes 1 you needed during this visit or previous visits? If not, what was left No 0 out?

Circle the first answer and record the information not given

E11 Did the provider clarify any Yes 1 concerns that you had? No 0

Had No concerns 2 If Yes or No, please record explanation

E12 Is the CBD accessibility convenient Yes 1 for you? No 0

E13 Did you get the services you went Yes 1 for? No 0

E14 Have you had any problems or Yes 1 difficulties as a result of services you received from this CBD? No 0

If yes, record the type of problem?

E15 When you were receiving Yes 1 counselling, where other people present? No 0

Not applicable 88

E16 Did the CBD reassure you that any Yes 1 information concerning your personal situation and the service No 0 you received will remain Not applicable 88 confidential?

100

E17 Do you feel that the time you spent Too long 1 with the CBD was enough? Just right 2

Too short 3

E18 Do you think that the environment Yes you were given the service was comfortable? No

If no, record why not?

E19 Did the CBD treat you in a friendly Yes 1 manner? No 0

If „no‟, record explanation:

E20 Have you been informed about the Ye No following? s When to return for your 0 follow-up visit. 1

That you can return at any time if you have questions or 0 problems. 1

101

E21 Was or is there anything in Record response particular that you liked about the CBD services?

E22 Was or is there anything in Record response particular that you disliked about the CBD approach?

E23 What suggestions can you make to Record response improve CBD performance and the services they provide?

102

E24 Would you recommend a CBD to a Yes 1 friend or relative? No 0

If no, record response why not?

SECTION F: Experiences and perceptions towards seeking and using contraceptives from other FP distribution approaches at community level

Thank you for sharing that information. Now let’s talk more about your experiences seeking and using contraceptives at community level.

NO. QUESTIONS CODING CATEGORY CODE SKIP

F01 Apart from CBD, which other Record the service provision contraceptive distribution points are points i.e. gov‟t HC, Drug there in your community? shop, CBD, outreach & others specify

103

F02 How did you learn about these Observation 1 providers of contraceptives/family planning? Friends/relatives 2

Mass media/radio 3

Hospital/health worker 4

CBD 5

Community outreach

You can tick more than one Others (specify)

F03 How close is the nearest gov’t Enter the time mentioned by Enter facility, drug shop or clinic to you? participant per distribution time point below:

Estimate distance using time spent walking to a CBD Drug shop

Clinic

Gov’t health facility

Others specify

104

F04 What type of contraceptives services Yes No do drug shops or clinic provide? FP counseling 1 0

Condoms 1 0

Emergency contraceptive 1 0 pills 1 0 Circle „1‟ if mentioned and „0‟ if Contraceptive pills not mentioned 1 0 Injectables 1 0 Implants 1 0 IUD 1 0 Natural family planning

Others (specify)

F05 What type of contraceptives services Yes No do the gov’t health facility within your community provide? FP counseling 1 0

Condoms 1 0

Emergency contraceptive 1 0 pills 1 0 Contraceptive pills Circle „1‟ if mentioned and „0‟ if 1 0 Injectables not mentioned 1 0 Implants 1 0 IUD 1 0 Natural family planning

Others (specify)

105

F06 Are the contraceptive services Yes 1 mentioned above always available? No 0

Unsure 88

F07 Have you ever sought contraceptives Yes 1 from these providers? No 0

If yes, record the specific If provider other than CBD NO  F22

F08 Did the visit happen in the past 12 Yes 1 months? No 0

F09 How many times have you accessed Enter a number services from these other service providers?

106

F10 What type of service did you seek? Yes No

FP counseling 1 0

Condoms 1 0

Circle „1‟ if mentioned and „0‟ if Pills 1 0 not mentioned Injectable 1 0

Emergency contraceptive 1 0 pills

Others (specify)

F11 Did you receive all the information Yes 1 you needed during this visit or previous visits? If not, what was left No 0 out?

Circle the first answer and record the information not given

F12 Did the provider clarify any Yes 1 concerns that you had? No 0

Had No concerns 2 If Yes or No, please record explanation

107

F13 Is the service point convenient for Yes 1 you? No 0

F14 Did you get the services you went Yes 1 for? No 0

F15 Have you had any problems or Yes 1 difficulties as a result of services you received from this CBD? No 0

If yes, record the type of problem?

F16 When you were receiving Yes 1 counselling, where other people present? No 0

Not applicable 88

F17 Did the PROVIDER reassure you Yes 1 that any information concerning your personal situation and the No 0 service you received will remain Not applicable 88 confidential?

F18 Do you feel that the time you spent Too long 1 with the provider was enough? Just right 2

Too short 3

F19 Do you think that the environment Yes you were given the service was comfortable? No

If no, record why not?

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F20 Did the health worker treat you in a Yes 1 friendly manner? No 0

If „no‟, record explanation:

F21 Have you been informed about the Ye No following? s When to return for your 0 follow-up visit. 1

That you can return at any time if you have questions or 0 problems. 1

F22 Was or is there anything in Record response particular that you liked about the drug shop or clinic services?

F23 Was or is there anything in Record response particular that you liked about the gov’t health facility services?

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E24 Was or is there anything in Record response particular that you disliked about the drug shop or clinic services?

F25 Was or is there anything in Record response particular that you liked about the gov’t health facility services?

F26 What suggestions can you make to Record response improve Drug shop or clinic provider’s performance and the services they provide?

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F27 What suggestions can you make to Record response improve gov’t health worker’s performance and the services they provide?

F28 Would you recommend a drug shop Yes 1 or clinic to a friend or relative to seek contraceptives? No 0

If no, record response why not?

F29 Would you recommend a gov’t Yes 1 health facility to a friend or relative to seek contraceptives? No 0

If no, record response why not?

Thank you for taking the time to talk to me today. The information you have shared with us is very helpful. Our study team will make every effort to keep what you told us confidential. Do you have any questions that I can pass on to the principal investigator who is in charge of the study?

Interviewer comments:

……………………………………………………………………………………………………… ………………………………………………………………………………………………………

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APPENDIX 4: FGD GUIDE

UPTAKE & FACTORS INFLUENCING CONTRACEPTIVE USE AMONG YOUTHS AT COMMUNITY LEVEL IN BUSIA, UGANDA

FGD GUIDE

INTRODUCTION Dear participants, You have been selected to participate in this study “Assessing the uptake and use of modern contraception among youths at community level in Busia, Uganda”. The purpose of this study is to assess contraceptive uptake and use among young people and also to describe the factors that influence youths’ uptake of contraceptives at community level.

The study findings are intended inform community based programs so as to improve contraceptive service provision such that CBD programs appeal and reach many youths. We will be asking clients about their experiences and perceptions towards contraceptive services at community level. We’ll also ask non clients why they are not seeking and what they want to see improved with community based contraceptive provision.

Having heard the information above, if you have any question about the study, raise it now. Feel free to ask further questions at any time. You are also free to withdraw from the study at any time. The interview will take about 60-90 minutes and will be kept completely confidential. If you agree to provide information to the researcher under the conditions of confidentiality set out on this sheet form, please register on the registration sheet. Your participation or refusal to participate in this interview will not affect the services you receive in any way. Your comments will help understand how to improve our services by highlighting areas of strength and improvement.

FGD participants will receive 10,000 shillings to compensate for your transport to and from the interview venue.

GENERAL BACKGROUND: (Note: This section is for building rapport and understanding context).

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1. Before we get started, could you tell me about yourself and your home life? Socio-demographic characteristics: age, education, marital status, number of children, desired number of children. (Note: follow-up at end of interview to complete information on worksheet and make sure that all important characteristics have been covered) 2. Who are all the people that you live with? 3. If working, what kind of work do you do? How long have you been doing this kind of work? 4. Are you married or in a relationship now? 5. How long have you been together with your husband/partner? 6. How would you describe your relationship with your husband/partner?

SECTION A: FOR CBD CLIENTS

Individual factors 1. Are you or your partner currently using any contraceptives? 2. What method/s are you or your partner currently using? 3. Have you discontinue family planning use in the past because of side effect? 4. Why are you using family planning? 5. Is your partner aware of your use of contraceptives? 6. Does he/she approve of it? 7. What about your family members and friends do they approve of it? 8. Where do seek your contraceptive services? FP community level Providers attitudes‟ actions and attitudes. (For every question probe for explicit information on each provider i.e. CBD, Drug shop operator & health worker) 9. When you arrive at a community level Provider, are you made to feel welcome? 10. Are community level Providers friendly? 11. Are community level Providers trustworthy and ensure privacy? 12. Do they ask unnecessary questions without telling you why? 13. Are community level Provider open-minded or they are judgmental at youths seeking contraceptives? 14. You can choose to see either male or female community level Provider?

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15. Can you choose to see a community level Provider with your partner or with a friend? 16. Are community level Providers able to answer all your questions about contraception to your satisfaction? 17. Do community level Providers understand young people’s concerns on sexuality and sexual relationships? 18. Do they let you express your problems in your own words? 19. Do they make you feel embarrassed? Community level Services factors 20. Are the community level FP services open to young people? 21. Are community level FP services easy to get to? 22. Is it clear when to go to a CBD and where to find him or her? Or Is it clear when to go to a health worker or drug shop operator and where to find them? 23. Since the service is within the community, is it possible for young people to get to it without drawing attention to them. 24. Can youths choose from a range of contraceptives: pills, Emergency contraceptives, injections and condoms)? 25. Are you referred for others contraceptive services you would like to receive? 26. Are community level FP services affordable for young people? 27. You are given full information on any contraceptive method you receive and others? 28. Can youths get advice on questions concerning their sexuality? 29. Are you referred to another place if a service cannot be provided? 30. Do community level FP service providers fill in client form? 31. Are you comfortable with the client form filling and are you are told why information is needed. 32. Do you have to seek appointments before you drop-in to access services? 33. Do you wait longer for the services? 34. How and when would like to access CBD/health center /drug shop services?

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35. Are there other ways you can give your opinions on CBD/health center /drug shop services? 36. Would you recommend this CBD/health center /drug shop service to a friend? 37. How did you hear about these services? 38. Was there anything that made it difficult for you to use CBD/health center /drug shop service or are there any improvement that you can suggest: 39. Any other comments?

SECTION B: FOR NON CBD CLIENTS

Contraceptive knowledge and accessibility

1. Do you know of contraceptives/family planning? 2. How did you learn about contraceptives/family planning? 3. Which modern contraceptives/family planning methods do you know? 4. What are contraceptives or family planning methods used for? 5. Which family planning method/s can prevent sexually transmitted infections (STIs) and HIV/AIDS? 6. Can youths use modern contraceptives/family planning methods? 7. In your community, where can you access contraceptives? 8. Are you aware of community based distributors of contraceptives/family planning in your community? 9. Are contraceptives easily assessed in your community? 10. How close is the nearest CBD/health center/drug shop to you? 11. What type of contraceptives services do they provide? 12. Are the services always available 13. Are you pleased with the contraceptive services available?

Attitude toward contraceptive and family planning

14. How many of you or your partners are currently using contraceptives?

15. How many of you or your partners have ever used modern contraception?

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16. If not, why are you not using family planning now?

17. What are the benefits you think one can derive from family planning?

18. What in your opinion are the negative effects of family planning?

19. Do you think youths should have access to contraceptives and why so?

20. What do you think about contraceptives being distributed within your community?

21. Are CBD/health center/drug shop services accessed by all people in your community irrespective of age, religion or social background?

Barriers to contraceptive uptake and use 22. Does your religious belief act as a barrier to contraceptive use? 23. Have you discuss with your spouse/partner about the use of contraception at any time? 24. Did your partner approve of use of contraceptives/family planning methods? 25. Is your family in support of your use of family planning? 26. Has money ever hindered you from the use of family planning? 27. What else hinders you from accessing modern contraceptive services in your community? 28. Are you aware of any CBD/health worker/drug shop in your community? 29. Can you easily access contraceptives from this CBD/health worker/drug shop anytime? 30. Have you ever been denied contraceptive/family planning service before? Probe at community level. 31. Have you ever been turned back/refused services from CBD/health worker/drug shop at any time of the day for any reason? 32. Does the environment in which CBD/health worker/drug shop operate in convenient for you? 33. What do you want to see changing with the current contraceptive services provision at community level (CBD/health worker/drug shop)?

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Thank you for participating in this discussion

If you have any questions, we can forward it/them to the principle researcher.

Comment: ------

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APPENDIX 5: IDI GUIDE FOR CONTRACEPTIVE PROVIDERS

UPTAKE OF MORDERN CONTRACEPTION AMONG YOUTHS AT COMMUNITY LEVEL IN BUSIA, UGANDA

IDI GUIDE

INTRODUCTION Dear participant, You have been selected to participate in this study “Assessing the uptake and use of modern contraception among youths at community level in Busia, Uganda”. The purpose of this study is to assess contraceptive uptake and use among young people and also to describe the factors that influence youths’ uptake of contraceptives at community level.

The study findings are intended to inform community based programs so as to improve contraceptive service provision such that CBD programs appeal and reach many youths. We will be asking community based contraceptive service providers about their experiences and perceptions providing contraceptive services to youths. The interview will be tape recorded to avoid interruptions during the discussion. The recorded materials will be destroyed after data analysis.

Having heard the information above, if you have any question about the study, raise it now. Feel free to ask further questions at any time. You are also free to withdraw from the study at any time. The interview will take about one and half hours and will be kept completely confidential. If you agree to provide information to the researcher under the conditions of confidentiality set out on this sheet form, please sign the consent form. Your participation or refusal to participate in this interview will not affect your position as a service provider in any way. Your comments will highlight areas of strength and improvement.

HEALTH PROVIDER DETAILS:

1. What is your village or name of health center or drug shop?

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2. How long have you worked in family planning provision at community level? 3. How many villages are in your area of service? 4. Are there drug shops, health centers or CBDs providing contraceptives in your community? 5. How many health facilities, drug shops and CBDs are there sin your area of service?

KNOWLEDGE: 6. What contraceptives/ family planning methods are on the Ugandan market? 7. Are there national guidelines or recommendations dictating to whom (age group or marital status) providers should distribute contraceptives and for whom they are advised against distributing contraceptives? 8. Is there any type of contraceptives which the national guidelines or recommendations prohibit providers to dispense to youuths? 9. What contraceptives/ family planning methods do you provide in your community? 10. What about the methods you do not provide, what do you do to the youths who wish to have them? 11. Is there demand for modern contraceptives among youths in your community? 12. What do you think influences this demand? 13. What do you think about youths using modern contraception? 14. Are youths aware of the contraceptive services that you provide? 15. If yes, how did they get to know about these the services at community level? 16. Describe the trends of youths seeking your services since you started distributing contraceptives in your community. 17. What contraceptives do you recommend youths to use? 18. Is there an official fee for family planning services? 19. Are there any other costs associated with receiving family planning services?

PRACTICES:

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20. Do you provide contraceptives every day, all day? 21. What is the official cost of contraceptives? 22. Are there other related costs for contraceptives? 23. What contraceptives are you currently providing in your community? 24. Are there any methods that you know about, but do not offer? If yes, why? 25. Does your supply of contraceptives last until the next refilling? 26. Did you have any stock out of any of the mentioned contraceptives in the past three months? 27. Where do you refer patients who want a method that is not available here? 28. Do you provide contraceptives/family planning methods to all people who request for it? Including adolescents and unmarried? 29. Have you ever distributed modern contraception or contraception-related counseling to youths? 30. Which contraceptives do you offer to youths? 31. Are there any methods that are available, but you do not recommend youths? If yes, which ones and why? 32. How frequently do you distribute contraceptives to youths? 33. Have you ever refused to provide contraceptives to a youth? 34. If yes, what were the reasons for refusing to distribute contraceptives? 35. When a youth comes in for family planning, does she/he request a specific method, or do you suggest one? 36. If you suggest a method, what criteria do you use to suggest which method? 37. What do you think youths want to see being done for them to freely and easily access contraceptive services at community level?

ATTITUDES & BELIEFS: 38. What do you think about unmarried youths in sexual relationships? 39. Do you (CBD) support provision or use of contraceptives among youths? 40. What do you think about use of contraceptives among unmarried youths?

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41. In what circumstances do you feel contraceptives are appropriate for young people (in case of unprotected sex, contraceptive failure/condom breaking, and rape)? 42. Are there particular situations when contraceptives are considered inappropriate for adolescent use? 43. Do you believe that contraceptive use among youths increases promiscuous behaviors of its users? 44. Do you support advanced provision of emergency contraception? 45. What is your opinion about repeat or routine use of non-dual protective contraception? 46. Do you have any norms and beliefs assisting you to implement your family planning services? 47. How do you think community based family planning services can be improved to better serve youths? 48. What do you think is needed to increase access to contraceptive/family planning services among youths? Thank you for participating in this interview If you have any questions about the study, we can forward it/them to the principle researcher.

Comment: ------

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