Improving Access and use of Emergency Contraception among Adolescents in the Tooro Sub-Region of Uganda: The Effect of the Reproductive Health Education Intervention

Abstract

Background: Adolescent pregnancies jeopardize the health of young people and have a negative impact on their lives. The consequences of adolescent pregnancies affect not just mothers but also their offspring. Most adolescent pregnancies are unplanned and unwanted. Modern family planning methods, as well as other preventive efforts, have been shown to reduce unplanned pregnancies. Emergency contraception (EC) in particular, has been identified as an effective method for preventing unwanted conceptions. However, recent literature demonstrates that adolescents are not using ECs or other modern family planning methods to prevent unwanted pregnancies. This study sought to investigate the factors influencing access and use of ECs among out-of-school adolescents aged 14 to 17 years in the Tooro sub-region of Uganda, using a Reproductive Health Education Intervention (RHEI). Methods: A quasi-experimental study approach was used in this study. Factors influencing access and utilization of emergency contraception among adolescents, guided by the PRECEDE PROCEED model were investigated. The study was carried out in three phases. Phase one consisted of the collection of baseline data. This was designed to determine the prevalence of EC use among adolescents, and their predisposing, reinforcing, and enabling factors. Predisposing factors included adolescents’ knowledge, attitudes, and perceptions of EC access and use. Reinforcing factors included the support of Village Health Teams (VHTs) and their referral of adolescents to access and utilize ECs. Enabling (health system) factors included the knowledge, attitudes, and practices of service providers, EC availability, distance to the health facility, and pricing of EC services. In the second phase, service providers from both private and public health facilities that provide ECs over the counter as well as members of the VHT were trained as part of a RHEI. The training was tailored to address gaps and challenges identified in the baseline study, and improve access and use of ECs among adolescents. The third phase comprised post intervention assessments at three and six months to determine the impact of the RHEI on adolescents’ access to and use of ECs. Data was collected using both qualitative and quantitative methods. The qualitative methods used included focus group discussions and key informant interviews, resulting in the in-depth descriptions and opinions of key stakeholders. This data was audio captured and processed with ATLAS-ti software, which created themes, sub-themes, and codes. The mystery clients’ approach was used to collect data on the quality of care provided by service providers. STATA version 16 was used to analyse quantitative data. Bivariate and multivariable logistic regression analysis was used to determine the relationship between predictor and outcome variables. The baseline, 3-month, and 6-month post-intervention data were analysed using the mixed-effect logistic regression modelling to account for the intra personal correlation over the time period of the intervention. Findings: Baseline data analysis indicated that the prevalence of sexual activity among adolescents in the study was 72.2%. The prevalence of modern contraceptive use was 32.9%. The prevalence of EC use among sexually active adolescents was 14.3%. A few of the adolescents in this study (14.9%) were knowledgeable about ECs. Only 21.2% expressed a positive attitude towards ECs. The knowledge, attitudes, and practices of service providers were assessed as low. The minority (26.7%) of care providers were knowledgeable about ECs provision to adolescents. Only 14.0% and 25.6% had a positive attitude and confidence to deliver not knowledgeable. The VHT's attitudes towards adolescent use of ECs were unfavourable, based, not just on cultural and religious affiliation, but also on the perceived side effects of ECs. Post-intervention assessments at 3 and 6 months demonstrated a positive effect on EC access and use among adolescents. The overall use of ECs increased from 14.3% to 44.3%. In independent groups, the prevalence of adolescents’ EC use increased from 13.0% at baseline to 58.4% in the intervention group at 6 months, while recording less increase from 16.0% to 26.3% in the control group at the same period. When compared to the control group, adolescents in the intervention group were 8 times more likely to use ECs (AOR = 8.07; 95% CI: 3.73–17.46; p<0.001) post intervention. Furthermore, when compared to the control group, adolescents in the intervention group were 12 times more likely to be knowledgeable about ECs (AOR = 11.71; 95% CI: 6.67– 20.54; p<0.001) and 16 times more likely to have a positive attitude to ECs use (AOR = 16.47; 95% CI: 8.39–32.35; p<0.001). The training also had an effect on service providers, thus increasing their knowledge, attitude, competence, and practice. Knowledge among service providers increased from 23.9% to 89.1%; positive attitude increased from 17.4% to 80.1%; and confidence increased from 23.9% to 97.8%. The mystery clients were able to notice an improvement in the service providers' level of quality-of-service provision when compared to the baseline assessment. Furthermore, when compared to the control groups, the members of the village health team in the intervention group were able to support and refer adolescents to facilities that provide ECs. Conclusions and Recommendations: The prevalence of sexual activity among adolescents is high, especially in the rural areas of Tooro sub-region of Uganda. Findings from this study indicate that modern contraception, including EC utilization, is low in this population. Limitations to use included low knowledge and limited access to ECs. The Reproductive Health Education Intervention (RHEI) improved access and use of ECs among adolescents. The Ministry of Health and other implementing agencies could employ the RHEI approach as it was effective at improving service providers' quality of EC provision to adolescents, while the VHTs were able to support and refer adolescents to health facilities for EC services. The Ministry of Health should adopt this simple but effective RHEI strategy to improve access and utilization of ECs and other modern contraceptives by adolescents. ECs to adolescents respectively. The members of the village health team (VHTs), on the other hand, lacked information and were unable to counsel adolescents about ECs because they were