Socio-economic and cultural factors affecting ...

African Journal for Physical, Health Education, Recreation and Dance (AJPHERD)

December 2013 (Supplement 1:1), pp. 32-42.

Socio-economic and cultural factors affecting adolescents’ accessibility to contraceptives in Vhembe District, Limpopo Province, South Africa D.U. RAMATHUBA, R.T. LEBESE, M.S. MAPUTLE AND L.B. KHOZA Department of Advanced Nursing Science, University of Venda, Thohoyandou, South Africa. E-mail:[email protected] Abstract Efforts have been made worldwide to assist adolescents to have a better understanding of sexuality and reproductive health and improve access to reproductive health services. However, majority of the youth still have no access to contraception and this limitation exposes them to unwanted pregnancy and sexually transmitted infections. The aim of the study was to explore and describe socio-economic and cultural factors which impact on adolescents’ accessibility to contraceptives by adolescents in Vhembe district. A qualitative research design which is explorative, descriptive and contextual in nature was used. The target population comprised 57 adolescents attending youth friendly clinic at the four primary health care facilities in Vhembe district. Data were collected through six focus group discussions until data saturation was achieved. Data were analysed using open coding method. Findings revealed that adolescents were not accessing contraceptive services freely due to interpersonal skills of nurses, inadequate comprehensive knowledge about contraception and contraceptives, and threatening environment. Socio-economic and cultural factors were also identified as barriers to accessibility of contraceptive. It is recommended that adequate information on contraception should be provided to adolescents to enable them make sound decisions about sexual behaviour based on knowledge and understanding of conception and contraception. Stereotypical thoughts and behaviour should be eliminated in the community through proper contraceptive education, counselling and enlightening them about the benefits of contraceptives. Keywords: Accessibility to contraceptives, adolescents, contraception, primary health care, sex education. How to cite this article: Ramathuba, D.U., Lebese, R.T., Maputle, M.S. & Khoza, L.B. (2013). Socio-economic and cultural factors affecting adolescents’ accessibility to contraceptives in Vhembe District, Limpopo Province, South Africa. African Journal for Physical, Health Education, Recreation and Dance, December (Supplement 1:1), 32-42.

Introduction Unplanned teenage pregnancy constitutes an important health and social problem in South Africa, and sexual maturation and sexual activity initiation are occurring much younger and have negative implications for adolescent reproductive health (Oni, Prinsloo, Nortje & Joubert, 2005). Reproductive health services are important in reducing the number of unplanned and unwanted pregnancies. According to WHO (2000), 75% of unintended pregnancies occur worldwide every year due to non-use of contraceptives.

Socio-economic and cultural factors affecting adolescents’ accessibility to contraceptives

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Kellner, Jooste and Jacobs (2010) reported that the way in which family planning services are delivered becomes the major obstacle for their use, thus improving family planning service delivery in line with client expectations is essential in putting the clients first. The teenagers in South Africa were often left out of the reproductive health care system due to lack of accessibility, unfriendly health services or unavailability of resources (Kempner, 2003). The emphasis on sexual health was often placed on married couples as the youth were expected to bring their parents’ consent when in need of family planning services (Kempner, 2003). The health personnel were often unfriendly towards teenagers trying to access family planning services. Unfriendly service could have contributed to lack of correct information dissemination to teenagers at a critical time of their development. Absence of parental approval and the attitude of health personnel may also have contributed to teenagers’ ignorance on issues of sexual health including the use of contraceptives and had impacted on the rate of Sexually Transmitted Infections (STIs), teenage pregnancy and teenage parenthood. Sexual health information from reproductive health services is often insufficient. The focus on sexual health education is sometimes missed in the different health care settings like STI and family planning clinics. In the STI clinic the top priority is treatment and prevention of further transmission and in family planning clinics the focus is on the prevention of unplanned pregnancy with different methods and this influences the extent to which teenagers are educated about issues of sexual health when they visit the health service (Kempner, 2003). In the study conducted by Mavundla and Williams (1999) it was also indicated that health education by health professionals had not been of help to teenagers, although health education was supposed to address basic needs. Contraceptive knowledge among adolescent girls in Vhembe district is low, accounting for high adolescent pregnancy rate, with more adolescent opting for termination of pregnancy as a method of contraceptive. The major reasons cited for poor accessibility of contraceptive included, fear of parental authority, morally wrong, fear of being ridiculed by health care providers (Lebese, Maputle, Ramathuba & Khoza, 2013). These findings indicate that much is needed to enhance accessibility contraceptives. During these community visits researchers observed that the number of adolescents coming for antenatal care at the clinics which was 1245 in 2010 (Makhado Municipality Reproductive and Child Health Clinics). This result in high mortality and morbidity rates related to teenage motherhood and this raises the following question “Are adolescents expectations of family planning services not addressed that they fall victims of unplanned pregnancies? It is therefore necessary to explore the factors that impact on accessibility of contraceptive/family planning services

34 Ramathuba, Lebese, Maputle and Khoza by adolescents in the rural areas of Vhembe district, Limpopo Province as such the purpose of the study were to explore and describe socio-economic and cultural factors that impact on accessibility of contraceptive/family planning services by adolescents in Vhembe district, Limpopo Province. The study could add to the existing body of knowledge regarding contraceptive accessibility by adolescent girls, thereby preventing unplanned pregnancies, Termination of Pregnancy (TOP) and problems related to teenage motherhood. Methodology Research design A qualitative, explorative, descriptive and contextual research approach was used. This design enabled the researchers to understand the perspectives of teenagers in accessing contraceptives, preventing unplanned and unwanted pregnancies in Vhembe district. One central question was used as a point of departure and more questions emanated from the discussions. Participants narrated their information related to factors influencing the accessibility of contraception in the rural areas. The information was described with quotations to ensure emphasis and trustworthiness. Population and sampling The population for this study consisted of adolescents in Vhembe district of Limpopo Province. Villages with high statistics of teenage pregnancies and STIs were sampled using the DoH Statistics (2011). Four villages from Vhembe district participated in this study. A purposive sample of adolescents between the ages of 13 to 19 was used. Only adolescents involved in an intimate relationship with a person of the opposite sex, same sex, having a child or pregnant were interviewed. A total of 57 adolescents made up of 24 males and 34 females were sampled and categorized into 6 focus groups. Ethical consideration Permission to conduct the study was obtained from the following institutions; Department of Education and Culture, the Chief in the villages where data was collected and School Governing Bodies. Ethical clearance from the University of Venda was obtained after oral presentation was made to the university ethics committee. Permission was also sought from the parents through an informed consent or assent depending on the participants’ ages. The consent form was translated into Xitsonga and Tshivenda by language experts in the school of education for easier comprehension by the participants. Participants were made aware of the use of audiotape. They were further shown a stop button so that they could stop the recording if they did not want some of the information to be


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recorded. Participants were also informed about voluntary participation as they were made aware of the fact that they were free to terminate participation in the study without fear of being punished. Private information of participants was not shared without the individual’s knowledge or against her will. Participant’s names were treated anonymously by using code names during interviews and filling of raw data. Data collection Data were collected through six focus group discussions. Information were tape-recorded, field notes and observational notes were taken. One central question that directed the interviews was: In your opinion what could be the factors that influence the accessibility of family planning/contraception by adolescents in this area? Hi ku vona ka wena I ncini lexi xi sivelaku vantshwa ku fikelela ku kunguhato (Xitsonga translation). Nga kuvhonelo kwanu, ndi mini tshine tsha kundiswa vhaswa u swikelela zwithivhela mbebo (Venda translation). This question was translated to local African languages for easier comprehension by the participants. The translation was done by Xitsonga and Venda educators in the department of African languages at the University. There was a back translation by another language educator to ensure English and Xitsonga/Tshivenda equivalence. Paraphrasing and probe follow up questions was done to deepen the discussions. Trustworthiness The principle trustworthiness was achieved through spending time with participants to gain their confidence. Participants were purposively sampled and prolonged engagement increased probing of information which enhanced data saturation. Tape recordings as well as field notes written during interviews increased the confirmability of the research. Transferability was ensured by complete description of research method, in-depth discussions of the data obtained and interpretation of the research findings in the study report. In-depth literature control on the topic of the study and verbatim quotes cited in the findings will enable readers to do self-evaluation of their own experiences of the phenomenon. Data analysis Data analysis was done simultaneously with data collection. Data were transcribed and then translated verbatim from Xitsonga/Venda to English by a language practitioner. Recorded information was also compared with transcribed data to avoid omissions. Data analysis was guided by eight steps of Tesch’s method in (Creswell, 2009). Literature control was done to ensure that

36 Ramathuba, Lebese, Maputle and Khoza there is a good fit between data and relevant literature, providing a link between previous studies and the present research. Results and Discussion Two themes emerged from the focus group discussions as well as categories. Table 1 gives a summary of results. The themes and categories were discussed in detail and were supported by direct quotes from inputs of adolescents’ statements. Literature control was done to verify the findings. Table 1: Summary of the themes and categories Themes 1. Factors related to use of family planning

2. Teenagers opinion on how to improve the use and accessibility of contraceptives

Categories • Inaccessibility of family planning services • Use of alternative method • Increasing access to schools by use of visiting nurse • Information dissemination by parents and nurses

Out of a total of 57 participants, 24 were males and 34 females. Their ages ranged from 13 to 19 years of age. Theme 1: Factors related to the use of family planning The use of family planning services in Vhembe district of Limpopo Province was found to be the challenge to most adolescents. This was confirmed by statements from participants which indicated challenges as inaccessibility of family planning services and use of alternative methods by participants. Inaccessible family planning Most of the participants indicated that they usually had to travel long distances to the clinics in order to access family planning services. Most of the adolescents who were attending school indicated that they have to travel this long distance after school which is normally after two o’clock in the afternoon, arriving late. Poor access was also mentioned as caused by lack of money as participants have to pay for transport which at most times is impossible as almost all adolescents were still at school and not working. One of the participants said ‘I would like to go for family planning but I am still at school and if I go after school it is already late as I have to travel for almost 10km to the clinic. There are also chores that I am expected to do at home. This is just difficult for me. Maybe if there was a nurse visiting the schools that would be better for me’. This was supported by the study which was done by Ziyane and


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Ehlers (2006) and Ritcher and Mlambo (2005) when citing reasons given by adolescents for not using contraceptives as cost and distance, thus inaccessibility, unavailability of family planning clinics. This could influence on the use of family planning services and increase unplanned and unwanted pregnancies. WHO (2006) points out that despite the advances in contraceptive technology, factors such as long distance to clinical sites, lack of transportation and clinic hours coinciding with school hours, especially if adolescents live in a remote area where facilities such as bus are nonexistent or expensive. Adolescents would be required to walk long distances to seek contraceptive services which would be another deterrent factor leading to poor utilization of the method. Adolescents might also feel intimidated by meeting their teachers, relatives, parents at the contraception services leading to under-utilisation of the clinic by adolescents (Kanku & Mash, 2010; Ritcher & Mlambo, 2005). Health providers were also said to be unwelcoming most of the times. Participants indicated that health personnel more than often scold them for using contraceptives while still young. Participants said that health personnel expect them to bring along their parents or their consent in order for them to give them the contraceptives. This is supported by the following quotation ‘it is so!!… difficult to deal with health personnel (exclamation). They don’t want us to use contraceptives and on the other hand they don’t want us to fall pregnant. I have an older sister who has a child and she gives me some of her pills as she does not have problems in getting the contraceptives. The participants further indicated that most of the times; the preferred contraceptives are not available in the clinics. This was said to be disruptive to the continuation of the course of the contraceptives and exposes participants to pregnancy ‘the clinics sometimes run out of stock and this makes us to default on the use of contraceptives’. Negative attitudes of nursing personnel in the clinics can lead to negative attitude towards family planning by adolescents and this can results in unplanned and unwanted pregnancies. This has also been reflected in a survey conducted by Ziyane and Ehlers (2006) in Swaziland where teenage girls reported to having to change their school uniforms for ordinary clothes prior to accessing contraceptives, which are denied to schoolgirls. Furthermore they were denied access to even condoms from the clinic. Rasch cited by Ziyane and Ehlers (2006) also reported that antagonism and resistance from contraceptive providers poses barrier to adolescents’ effective utilisaton of contraceptives. Ramathuba (2008) and Tu, Gao and Yuan (1997) reported similar findings where health workers approved that government must provide young unmarried adults with contraceptives, whilst 36% disapproved and 4% did not

38 Ramathuba, Lebese, Maputle and Khoza respond. The family planning providers from urban areas indicated that they don’t consider the young unmarried as their target population for contraceptives. The prominent factor being that they associate sexuality with marriage and childbearing and considered drug stores to be the most acceptable place to provide contraception services, whereas the rural community was acceptable because of the custom of engagement before marriage is common in rural areas and that there are fewer drug stores. Maja (2007) reported that although health care services, mainly clinics are within reasonable reach within communities they are not used effectively due to various barriers, such as failing to provide clients with methods of choice or continual contraception because of lack of stock. Furthermore, Oni, Prinsloo, Nortje and Joubert (2005) also indicated that staff at family planning clinics does not address the expectations of teenagers, as some service providers do not even explain the method of contraception to them and these may hamper effective utilisation. Use of alternative method The participants mentioned that they also used alternative methods of contraception. This was identified as another contributory factor to poor utilisation of available contraceptive services. Some of the participants described these as myths related to contraception. It was noted with concern that the following myths were said to prevent pregnancy: ‘They told me to prevent pregnancy by having sex in the rain, or drinking ENO after intercourse.’ This was observed as being risky because participants were not protected against unwanted pregnancy and were at risk of contracting STIs. In some cases, fears resulting from misconceptions about contraception contribute to none usage (Orji, Adegbenro & Olalekan, 2005). The use of traditional method was identified as another barrier to the use of contraceptives by adolescents. Participants indicated that some use a certain herb to prevent pregnancy and this was identified as being risky as the method is not proven to be successful’. One participant said, ‘you know there is a herb that I am using that had been shown to me by my aunt. I use it before sex and it has been helpful as I have not fallen pregnant since then’. Otoide, Orosaye and Okonofua (2001) in the study done in Nigeria also reported similar findings that, sexually active adolescents gave in-depth list of traditional methods and gave details of their uses and sources of traditional contraceptive method. Kibret (2003) also indicated that inadequate knowledge of how a pill prevents pregnancy and, how it needs to be taken, can put women at risk of unplanned pregnancy. It has been estimated that one in five unplanned pregnancies may be due to women's lack of knowledge about the pill.


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Theme 2: Teenagers’ opinion on how to improve the usage of contraception The participants indicated how the usage of contraceptives by teenagers can be enhanced in the rural areas. They felt that if access and proper information is given to them they can better utilise the services. In giving their opinions the following sub-themes emerged: • •

Increasing access to schools by use of visiting nurse Information dissemination by parents and nurses.

Sub-theme 2.1: Increasing access to schools by use of visiting nurse Teenagers felt that the Department of Health could increase access to contraceptives by having a schedule that could be monthly by allocating a nurse or nurses to visit the schools and provide the service to them. This will assist them as they have to travel long distances to the clinics late after school which is not always possible because as students they have homework and chores to do at home. This was expressed by some of the following quotations:’ if there were nurses visiting the schools at regular intervals I think we could be well informed and not run out of contraceptive as most of the times it is not possible to go to the clinic’ Another informant said ‘it is very difficult to go to the clinic after school as one need to do home work and household chore. The clinic is very far and one cannot manage to go there during the week and over the weekend nurses do not want to attend to non emergency cases as the staff is too little’. Ndyanabangi and Kip (2002) were of the opinion that an effective strategy could be to foster partnership of school-based reproductive health and the department of health by integrating approaches/systems. Training programmes regarding reproductive health and sexual information could be offered jointly by the ministry of education as a multisectoral initiative. In addition, contraceptives could be made available on school campuses. Sub-theme 2.2: Information dissemination by parents and nurses Teenagers explained how parents should take the lead in teaching them about issues related to contraception. They felt that parents can be trusted by their children and information that they can give to them will be trusted and used. If was also pointed out that nurses do not have time to explain how to use and the side effects of contraception which makes them to use contraceptives wrongly, hence the high pregnancy rates. It was stressed that nurses should give themselves time to give enough information when giving contraceptives to ensure proper use by teenagers. For example one participant stated ‘parents do not teach us about contraceptives this is a topic that is not discussed. I think

40 Ramathuba, Lebese, Maputle and Khoza parents should possess more information about contraceptives as we trust their advises and one can have somebody to refer to when experiencing problems’ Poor knowledge about contraception had been reported by Arai (2003) but other studies by Bankole, Ahmed, Ouedraogo and Konyani (2007) have reported that teenagers are well informed about contraception. It has been noted by Abiodun and Balogun (2008) that although teenagers had sufficient knowledge about contraception gaps still existed in the accuracy of their knowledge or skill regarding correct use of contraceptives. Incorrect usage was said to cause tears in condoms and missed contraceptive pills. A study conducted in Limpopo Province of South Africa by Wood and Jewkes (2006) reported that girls in that province used contraceptive pills when their partners visited them, or use half the number of contraceptives to prevent being overweight and stopping contraceptives because of amenorrhea. This can also be influenced by poor information that teenagers have in relation to the use of contraceptives. Limitation of the study This study was conducted in one District of Limpopo Province and cannot be generalised to other districts in the Province. The focus group method may have limited the extent of information sharing by participants. Future studies should endeavour to involve more districts in the province as well as explore other methods of data collection. Recommendations of the study Based on the findings of the study, the following recommendations were made to facilitate the access of contraceptives by adolescents in Vhembe district, Limpopo Province. •

•

•

Health care providers work collaboratively with communities in the development of the contextual health education that include, more information on human sexuality, conception and contraception to eliminate cultural barriers/misconceptions about contraceptives. Girls should have access to confidential counselling and quality contraceptive information and service, including emergency contraception should be made available twenty four hours even during weekends. Reproductive health should be extended to schools through school health services to ensure accessibility of contraceptives, adolescents would not incur extra travel costs and compliance will be ensured in preventing unwanted pregnancies.


•

•

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Negative attitudes and lack of knowledge about contraceptives should be eliminated through proper contraceptive education and counselling and enlightening adolescents about the benefits of contraceptives and how to manage side effects of contraceptives. Community workshops can be provided through collaboration with different sectors in the community like churches, non-governmental institutions, health workers and parents to enforce awareness on the importance of opening sexual communication with adolescents to eliminate misconceptions relating to sexual health.

Conclusion The study explored and described socio-economic and cultural factors which provided important insight in ensuring that adolescents need to be provided with contraceptive information, education and counseling programmes. For contraceptives to be accessed and utilised effectively health care providers should demonstrate good interpersonal skills and provide appropriate and acceptable methods of contraceptives that are designed to meet the clients’ needs. Cultural barriers to contraceptives use should be removed and parents need to be empowered to talk openly about sexuality. References Abiodun, O.M. & Balogun, O.R. (2008). Sexual activity and contraceptive use among young female students of tertiary educational institutions in Ilorin, Nigeria. Contraception, 9(79), 146-149. Arai, L. (2003). Low expectations, sexual attitudes and knowledge: Explaining teenage pregnancy and fertility in English communities. Insights from qualitative research. The Sociological Review, 13(51), 199-217. Bankole, A., Ahmed, F.H., Neema, S., Ouedraogo, C. & Konyani, S. (2007). Knowledge of correct condom use and consistency of use among adolescents in four countries in Sub-Saharan Africa. African Journal of Reproductive Health, 9(11), 198-220. Creswell, J.W. (2009). Research Design: Qualitative and Quantitative Approaches. London: SAGE publications. Democratic Nursing Organisation of South Africa (DENOSA) (1998). Ethical Standards for Nurse Researchers: DENOSA. Pretoria. Department of Health (2011). National Contraception Policy Guidelines. Pretoria: Government Printer. Kanku, T. & Mash, R. (2010). Attitudes, perceptions and understanding amongst teenagers regarding teenage pregnancy, sexuality and contraception in Taung. South African Family Practitioner, 52(6), 563-572.

42 Ramathuba, Lebese, Maputle and Khoza Kellner, A., Jooste, K. & Jacobs, W. (2010). Perceptions of clients regarding family planning service delivery in a clinic of the Greater Johannesburg Metropolitan Council. Curationis, 33(2), 13-24. Kempner, M.E. (2003). True integration of prevention programmes requires broad focus on sexual health. SIECUS Report. Academic Research Library, 31 (3), 44-51. Kibret, M. (2003). Reproductive health knowledge, attitude and practice among school students in Bahar Dar, Ethiopia. African Journal of Reproductive Health, 7(2), 39-45. Lebese, R.T., Maputle, S.M., Ramathuba, D.U. & Khoza, L.B. (2013). Factors influencing the uptake of contraception services by Vatsonga adolescents in rural communities of Vhembe District in Limpopo Province, South Africa, HealthSAGesondheid 18(1), Art.#654,6pages.http://dx.doi.org/10.4102/hsag.v18i1.654 Maja, T.M.M. (2007). Involvement of males in promoting reproductive health. Curationis 30(1), 71-77. Mavundla, T.R. & Williams, C.X. (1999). Teenage mothers’ knowledge of sex education in general hospital of Umtata district. Curationis, 22 (1), 58-63. Ndyanabangi, B. & Kip, W. (2002). Reproductive health and adolescent school students in Kabarole district, western Uganda: A qualitative study. Journal of Health & Population in Developing Countries, 3(2), 1-20. Oni, T.E., Prinsloo, E.A.M., Nortje J.D. & Joubert, G. (2005). High school students ‘attitudes, practices and knowledge of contraception in Jozini, KwaZulu- Natal. South African Family Practitioner, 47(6), 54-57. Orji, E.O., Adegbenro, C.A. & Olalekan, A.W. (2005). Prevalence of sexual activity and family planning use among undergraduates in south west Nigeria. European Journal of Contraceptive, Reproductive Health Care, 10(4), 255- 260. Otoide, V.O., Oronsaye, F. & Okonofua, F.E. (2001). Why Nigerian adolescents seek abortion rather than contraception: Evidence from focus group discussions. International Family Planning Perspectives, 27(2), 77-81. Ramathuba, D.U. (2008). Knowledge and attitudes of secondary school girls towards contraception. Unpublished MCur dissertation. Thohoyandou, University of Venda. Richter, M.S. & Mlambo, G.T. (2005). Perceptions of rural teenagers on teenage pregnancy. Health SA Gesondheid, 10(2), 61-69. Tu, X.W., Gao, E.S. & Yuan, W. (1997). Factors influencing premarital contraceptive use at time of first intercourse among women in Shanghai. Population Science, 61(4), 57-64. Wood, K. & Jewkes, R. (2006). Blood blockage and scolding nurses: Barriers to adolescent contraceptive use in South Africa. Reproductive Health Matters, 7(14), 109-118. World Health Organization (2006). Report of a WHO Technical Consultation on Birth Spacing. http://www.who.int/making_ pregnancysafer/publications/ policy_brief_birthspacing. pdf, accessed on 12.08.2011. Ziyane, I.S. & Ehlers, V.J. (2006). Swazi youth’s attitudes and perceptions concerning adolescent pregnancies and contraception. Health SA Gesondheid, 11(1), 31-42.