Nurses' perceptions of adolescents accessing and utilizing sexual and reproductive healthcare services in Cape Town, South Africa: A qualitative study

Socio-Ecological Analysis of Barriers to Access and Utilization of Adolescent Sexual and Reproductive Health Services in Sub-Saharan Africa: A Qualitative Systematic Review

Background

In sub-Saharan African countries (SSA), despite the efforts to enable adolescents to access sexual and reproductive health (SRH) services, there are limited systematic review studies that comprehensively synthesize barriers to accessing services using a social-ecological model. Therefore, this review was conducted to fill this gap.

Methods

This study protocol was registered in the PROSPERO database (CRD42022259095). We followed PRISMA guideline to conduct this review. PubMed, Google Scholar, Embase and African Journal Online databases were used. Two authors individually screened articles. Only qualitative articles published in the English in last 10 years were included in this review.

Results

From the total of 4890 studies, 23 qualitative studies fulfilled the eligibility criteria. Those studies were from 11 SSA countries. This review finding revealed that inadequate information about the services, the incorrect perception about services, low self-esteem, fear of being noticed by family members, and financial constraints are barriers at the intrapersonal level. Unsupportive families and lack of open communication between adolescent-parent about sexuality issues were interpersonal barriers to access. Lack of provider competency, provider attitude, an unsupportive environment, physical inaccessibility of services, and shortage of medicine, and supplies were identified as institutional-level barriers. Moreover, community-level barriers like community stigma, social, religious, and gender norms within the society were identified as the main barriers to accessing services for adolescents.

Conclusion

This review finding reveals that the main barriers to access SRH services for adolescents living in SSA are misperception about services, low self-esteem to access services, financial constraints, unsupportive families, community stigma and social norms, unsupportive environments in health facilities, healthcare provider behavior, poor competency, being judgmental attitude, and breaking privacy and confidentiality. This study finding calls for new approach like a multi-pronged that works with service providers, with community, with families, and with adolescent to improve SRH services utilization of adolescent.

Are respectful maternity care (RMC) interventions effective in reducing intrapartum mistreatment against adolescents? A systematic review

Intrapartum mistreatment of women by health professionals is a widespread global public health challenge. It leads to a decreased quality of maternity care and is evinced to precipitate detrimental maternal and neonatal outcomes, especially among adolescents. Relatedly, research indicates that Respectful Maternity Care (RMC) interventions are especially effective in mitigating intrapartum mistreatment and improving birth outcomes. However, evidence on the success of RMC, specifically for adolescents, is insufficient and unaggregated. Accordingly, this review specifically aims to synthesize existing evidence on RMC care provision to adolescent parturients. This review searched for relevant literature from published and gray sources including PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, as well as Population Council, WHO and White Ribbon Alliance data sources published between January 1990 and December 2021. Based on eligibility, studies were selected and quality appraised after which thematic analysis and narrative synthesis was conducted. Twenty-nine studies were included in the systematic review. Due to paucity and heterogeneity of quantitative studies, the review was limited to a thematic analysis. Adolescent and health provider perspectives alike underscored the burden and outcomes of mistreatment. Need for RMC interventions to improve quality of maternity care was recommended by majority of studies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42020183440.

Hope, agency, and adolescents' sexual and reproductive health: A mini review

Availability of and access to services that promote sexual and reproductive health (SRH) amongst adolescent girls have become a global priority. Yet, while researchers have explored factors that influence the uptake of SRH services in low-and-middle income countries, the roles that "agency" and "hope" play in adolescent SRH is less understood. To study this, this mini review systematically reviewed the literature across three databases, EBSCO-host web, Pubmed and South Africa (SA) epublications, for the period of January 2012 to January 2022. Findings showed that a paucity of studies identified the link between agency, hope and adolescent SRH respectively. Our review included 12 articles and found no studies that focused on hope and its role in adolescent SRH or seeking SRH services. However, the literature revealed the complexities of adolescent SRH agency and autonomy where female adolescents had limited autonomy to make SRH decisions. Limited access to adolescent friendly SRH services was also found to restrict girls' agency to prevent unintended pregnancies or to take up SRH support. Given the paucity of research, empirical studies are needed to further understand the extent to which hope, agency and other subjective factors implicate adolescent SRH in the African context.

Levels and sources of adolescents' sexual knowledge in traditional societies: A cross-sectional study

Gender rules, patriarchy, and cultural taboos on sexual issues in traditional societies may compel adolescents to seek sexual information from informal and inadequate sources. The aim of this cross-sectional study was to determine whether the level and sources of sexual knowledge differed by gender in the traditional community comprising Palestinian-Israeli high school students. Guided by the Human Ecological Systems Model and informed by a community-based participatory research approach, a convenience sample of high school students (n = 558) was recruited. Although findings indicated that both boys and girls had low levels of sexual knowledge, the areas of knowledge deficits varied by gender. The model demonstrated good fit for boys but not for girls. Post hoc analyses indicated that girls obtained sexual knowledge solely from close family members, while boys obtained sexual knowledge from multiple sources. Very few students of either gender obtained sexual knowledge from doctors or nurses, but with community input on cultural issues, nurses can play a pivotal role in creating comprehensive, school-based sex education for adolescents living in traditional societies.

Preferences for accessing sexual and reproductive health services among adolescents and young adults living with HIV/AIDs in Western Kenya: A qualitative study

Despite the need, adolescents and young adults (AYAs) in resource-limited settings have limited access to sexual and reproductive health (SRH) care services for improved health outcomes. This is worse for AYAs living with HIV in resource-limited settings where much is unknown about contexts and issues inhibiting access to SRHs. We explored adolescents', healthcare workers, and caregivers' preferences for access to sexual and reproductive health services for adolescents and young adults living with HIV. We conducted 30 in-depth interviews and 8 focus group discussions among a subset of AYA aged 14-24 living with HIV, healthcare workers, and caregivers/parents. We recruited participants from Lumumba Sub-County Hospital (KLM) and Kisumu County Referral Hospitals in Kisumu County (KCH). Trained and experienced qualitative research assistants 5-10 years older than the adolescents conducted interviews and facilitated discussions using guides designed to elicit detailed views and perspectives on sex and sexuality, access to SRH services, challenges of AYA living with HIV, and potential interventions to improve access to SRH services. Audio files were transcribed verbatim and translated to English where necessary before coding and analysis. We applied constant comparative analysis for theme and content to arrive at our conclusions. Our analysis yielded two main themes: preferences for a venue for SRH services and choices for qualities of an SRH counsellor. We found that AYAs generally preferred receiving SRH services to be co-situated within clinical facilities. We also observed gender differences in the qualities of SRH providers, with male AYAs preferring older male service providers compared to females who preferred younger female providers close to their age. The study highlighted the preferences of AYAs for accessing SRH, which need to be considered when designing their health programs. Further, AYAs seem to endite health systems to individualize access to SRH for AYAs living with HIV by providing a combination of attributes that meet individual preferences.

“She is courageous because she does not care what people think about her…”: attitudes toward adolescent contraception use among Rwandan family planning providers and adult female modern contraceptive users

Introduction

In Rwanda, only 20% of sexually active unmarried young women use family planning as compared to 64% of married women. Adolescence is an important time of growth and development that often includes the initiation of sexual activity. Sexually active adolescents need support in accessing contraceptive services to prevent negative health outcomes. In sub-Saharan Africa, the adolescent population represents a large share of the total population and that proportion is predicted to expand over time. Adolescent contraceptive needs have largely been unmet, and with growing numbers, there is increased potential for negative health sequelae. Due to the low use of contraception by adolescents in Rwanda, and the growing population of adolescents, this study aims to explore the perspectives of family planning providers and adult modern contraceptive users on adolescent contraceptive use. Inclusion of adult community members in the study is a unique contribution, as research on adolescent contraceptive use in sub-Saharan Africa relies primarily on perspectives from adolescents and family planning providers.

Methods

This qualitative study in 2018 utilized 32 in-depth interviews with modern contraceptive users and eight focus group discussions with family planning providers. Respondents were from Musanze and Nyamasheke districts in Rwanda, the districts with the highest and lowest modern contraceptive use among married women, respectively. Coding was conducted in Atlas.ti.

Results

Stigma regarding premarital sex results in barriers to adolescent access to contraceptive services. Family planning providers do provide services to adolescents; however, they often recommend secondary abstinence, offer a limited method selection, and accentuate risks associated with sexual activity and contraceptive use. Providers support adolescent clients by emphasizing the need for privacy, confidentiality, and expedient services, particularly through youth corners, which are spaces within health facilities designed to meet youth needs specifically. Modern contraceptive-using adult female community members advocate for youth access to contraception, however mothers have mixed comfort discussing sexual health with their own youth.

Conclusion

To destigmatize premarital sexual activity, government efforts to initiate communication about this topic must occur at national and community levels with the goal of continued conversation within the family. The government should also train family planning providers and all health personnel interacting with youth on adolescent-friendly health services. Dialogue between community members and family planning providers about adolescent access to contraceptive services could also reduce barriers for adolescents due to community members’ generally supportive views on adolescent contraceptive use. Efforts to engage adolescent caregivers in how to talk to youth about sex could also contribute to expanded use.

In Rwanda, youth who are having sex use family planning less than married women. This study involved asking family planning providers and adults what they think about youth using family planning. Data for this study was collected in 2018, and included 32 interviews with adult family planning users and eight group discussions with family planning providers in two areas of Rwanda. The findings show that Rwandans believe youth should not have sex before they are married. Family planning providers do provide youth with services; however, they often push stopping sexual activity, offer a smaller selection of family planning methods, and exaggerate risks associated with sex and family planning use. Family planning providers support youth by honoring their need for privacy, keeping their secrets, and providing fast services so fewer people see them at the clinic. Providers like to help adolescents in youth corners, which are special spaces within health facilities just for youth. Importantly, adult women who use family planning want youth in their community to be able to use family planning, too. In order to respond to the issues raised, the Rwandan government can start conversations in villages and more broadly about the need for youth to have access to family planning. The government should also teach family planning providers and anyone who comes into contact with youth to offer helpful and friendly services. Setting up spaces for adults to talk with family planning providers about youth access to family planning could also contribute to fewer barriers to services for adolescents.

Providers' approaches to contraceptive provision in Cape Town

Background

Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs.

Methods

Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach.

Results

Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services.

Discussion

Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

[Sexual and reproductive health of adolescents living with HIV in pediatric care programs in Abidjan : Structured provision of care and perceptions of health care workers in 2019]

INTRODUCTION

The majority of adolescents living with HIV (ALHIV) reside in sub-Saharan Africa, with sexual and reproductive health (SRH) needs to be met. The health care facilities and professionals involved have a major role to assume in the quality of SRH services offered to these teenagers.

OBJECTIVE

To investigate the SRH services offered to ALHIV subjects in pediatric facilities in Abidjan, Ivory-Coast.

METHODS

In 2019 we conducted an exploratory cross-sectional study using qualitative and quantitative methods in three pediatric facilities caring for ALHIV subjects (CIRBA, CTAP and CePReF) and participating in the IeDEA (International epidemiologic databases to Evaluate AIDS project) in Abidjan, Ivory Coast. This study included: (1) an inventory of SRH services, using a questionnaire and direct observation, describing their adaptation to the teenagers' needs and their inclusion in provision of care; (2 an assessment by means of semi-structured interviews of 14 health professionals' perceptions of the SRH needs of the ALHIV subjects with whom they worked. Quantitative data were expressed in percentages and qualitative data from the interviews were analyzed through inductive thematic analysis.

RESULTS

The care provided in the three facilities was poorly adapted to the teenagers' needs. Few SRH services were effectively provided to the ALHIV subjects in the different centers. The services essentially consisted in condom distribution and organization of SRH-based focus groups. Exceptionally, hormonal contraception was offered to teenage girls. Barriers to the services were largely due to poorly equipped facilities, particularly in terms of SRH offer, health professionals' experience, and support provided for ALHIV subjects and their parents. The health professionals were desirous of SRH skill-building programs enabling them to deliver optimal, adequately contextualized SRH services to the teenagers.

CONCLUSIONS

In pediatric programs addressed to ALHIV subjects in three Abidjan facilities, the teenagers' SRH needs remain unmet. It is urgently necessary to strengthen the health facilities by means of improved equipment, enhanced awareness of teenagers' needs, and training programs enabling the health professionals to provide more adapted sexual and reproductive health services.

Shifting Social Norms and Adolescent Girls' Access to Sexual and Reproductive Health Services and Information in a South African Township

Despite policy on adolescent sexual and reproductive health (SRH) services and education, teen pregnancies remain common in South Africa. Social norms and cultural resistance are a well-documented challenge for SRH program implementation in South Africa, and beyond. To gain insight on the complex picture of adolescents' access to SRH information and services in a peri-urban township, we explored this topic from a diversity of perspectives, carrying out 86 interviews to capture perceptions of adolescents, their parents, community members, and health professionals. Our research shows that despite the taboo nature of the issue of adolescent SRH, individual positions on adolescent access to SRH services and information are shifting and diverse, and are influenced by factors other than cultural norms. This research serves as a reminder to avoid simplistic reference to "culture" as a way of explaining health-related behaviors and people's responses to health challenges.

A mixed reception: perceptions of pregnant adolescents' experiences with health care workers in Cape Town, South Africa

Background

Maternal mortality among adolescent mothers in South Africa is higher than many middle-income countries. This is largely attributable to conditions that can be prevented or managed by high quality antenatal care. The way in which pregnant adolescents are treated at antenatal clinics influences their timely utilization of antenatal services. This qualitative study reports on the experiences of pregnant adolescents with health care workers when accessing antenatal care.

Methods

Pregnant girls aged 13–19 (n = 19) who attended public health care facilities that provide Basic Antenatal Care (BANC) services in Cape Town, South Africa were recruited. Four face to face in-depth interviews and four mini focus group discussions were undertaken, facilitated by a topic guide. Thematic analyses were used to analyse the data.

Results

Experiences that reinforce antenatal attendance, such as respectful and supportive treatment, were outweighed by negative experiences, such as victimization; discrimination against being pregnant at a young age; experiencing disregard and exclusion; inadequate provision of information about pregnancy, health and childbirth; clinic attendance discouragement; and mental health turmoil.

Conclusions

There is evidence of a discordant relationship between the health care workers and the pregnant adolescents. Adolescents feel mistreated and discriminated against by the health care workers, which in turn discourages their attendance at antenatal clinics. Maternal health care workers need to receive support and regular training on the provision of youth friendly antenatal care and be regularly evaluated, to promote the provision of fair and high quality antenatal services for adolescent girls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01211-x.

Antenatal care is the routine health care of pregnant women in order to diagnose pregnancy complications and to provide information about lifestyle, pregnancy and delivery. Maternal deaths among teenage mothers in South Africa is high and is largely due to conditions that can be prevented or managed by high quality antenatal care. Timely and routine antenatal care is therefore crucial for pregnant teenagers. The way in which pregnant teenagers are treated by health care workers at antenatal clinics influences their clinic attendance. This study reports on the experiences of pregnant teenagers with health care workers, when accessing antenatal care in Cape Town, South Africa. Nineteen pregnant girls aged 13–19 years were interviewed. Some positive experiences such as respectful and supportive treatment were reported. However, more negative experiences were reported, including victimization; discrimination against being pregnant at a young age; feeling disregarded and excluded; a lack of information about pregnancy, health and childbirth; being discouraged from attending the clinics; and mental health distress. In conclusion, many teenagers felt mistreated and discriminated against by the health care workers, which discouraged their clinic attendance. Maternal health care workers in South Africa need to receive support and regular training to provide youth friendly antenatal care to teenage girls.

Adolescent Pregnancy and Parenting: Perceptions of Healthcare Providers

BACKGROUND

Adverse maternal and child health outcomes due to adolescent pregnancy are central to public health research and practice. In addition, public health has emphasised that the care rendered by healthcare providers plays a pivotal role in the health and well-being of pregnant and parenting adolescents. Healthcare providers may differ in the ways they interpret adolescent pregnancy and parenting and consequently, this may have profound implications for healthcare decision making. The aim of this study was to explore the multiple perspectives of a diverse group of healthcare providers' delivering services and engaging with pregnant adolescents and adolescent mothers at a district hospital in Ugu, KwaZulu Natal, South Africa.

METHODS

This descriptive qualitative study used semi-structured interviews (n=33). Healthcare providers rendering care to pregnant and parenting adolescents were recruited from the maternity, antenatal, paediatrics, psychology, dietetics, physiotherapy and social work departments, as well as from the HIV/AIDS, STIs and TB (HAST) programme. The data were analysed using thematic analysis.

RESULTS

The healthcare providers acknowledged that adolescent pregnancy is a problematic issue in Ugu district. Furthermore, they felt that the postpartum sexual-related and reproductive health of adolescent mothers was not given priority. In the healthcare providers' view, the problems experienced by pregnant and parenting adolescents were school dropout, financial constraints, breakdown of relationships, abandonment, stigmatisation, parenting and child rearing difficulties, and both physical and mental health problems.

CONCLUSION

This study highlights that the issue of sexual- and reproductive-related outcomes of adolescent pregnancy and parenting is not given priority. In addition, the findings also highlighted the need for a multidisciplinary approach to the care of pregnant and parenting adolescents. Multidisciplinary communities of practices as interventions can be used to generate and share knowledge, capacitate healthcare providers and improve clinical practice. The training of healthcare providers, provision of non-judgemental counselling and tailored services for pregnant adolescents and adolescent mothers are essential. When appropriately disseminated, the findings will assist relevant healthcare providers, administrators in healthcare institutions, policymakers, and officials of the Department of Health and the Department of Education in South Africa to address the lack of appropriate care for pregnant and parenting adolescents.

Perceptions of contraception services among recipients of a combination HIV-prevention interventions for adolescent girls and young women in South Africa: a qualitative study

Background

Adolescent girls and young women (AGYW) in low- and middle- income countries (LMICs) have high rates of unintended pregnancies and are at higher risk for HIV infection compared to older women of reproductive age. Using a socio-ecological model approach, this research investigated perceptions of contraception services among AGYW who had been recipients of a combination HIV-prevention intervention, to better understand factors affecting their access to and use of contraception services.

Method

Qualitative methods used in this study included focus group discussions (FGDs) and in-depth interviews (IDIs) with 185 AGYW aged 15–24 years living in five of the ten intervention districts. All interviews and FGDs were audio-recorded and data were analyzed thematically using Nvivo 12 software with manual identification of themes and labelling of raw data.

Results

The findings reveal that many AGYW, especially those in the younger age group 15–19 years, experience difficulties in accessing contraception services, mainly at the interpersonal and health service levels. Lack of support for the use of contraceptives from parents/caregivers as well as from sexual partners were key barriers at the interpersonal level; while providers’ negative attitude was the main barrier at the health service level. The majority of school-going AGYW felt that bringing contraception services and other sexual and reproductive health (SRH) services on to the school premises would legitimize their use in the eyes of parents and help to overcome barriers related to parental support and acceptance, as well as overcome some of the health service and structural level barriers. However, views among school-going AGYW about school-based provision of contraception services were mixed, clouded with concerns relating to confidentiality.

Conclusion

Interventions to improve parental/caregiver and sexual partner support for the use of contraception services by AGYW, as well as efforts to expand the provision of contraception services on the school premises are urgently needed. Future interventions should incorporate multi-level approaches to address structural and contextual barriers to access and use of contraception services to gain maximum effect.

[Level of knowledge about insulinization by Primary Care physicians and its impact on diabetes control]

OBJECTIVE

To determine the level of knowledge and current management of starting insulin treatment by Primary Care physicians, and its impact on metabolic control.

MATERIALS AND METHODS

A mainly qualitative exploratory sequential study, with a phenomenological approach, followed by a quantitative phase. The study included 37 primary care physicians from the Andalusian Health Service. Socio-demographic and clinical care variables were analysed. Univariate and bivariate analyses were performed.

RESULTS

There was a wide variability between Primary Care physicians in the level of knowledge of treatment with insulins (low knowledge: 13.5%; medium knowledge: 59.5%; high knowledge: 27.0%). There was a direct relationship between the level of knowledge and the attainment of HbA1c goals (as the level of knowledge increased, the metabolic control improved). The most common basal insulins prescribed were insulin glargine U-100 (56.8%), followed by insulin glargine U-300 (29.7%), and neutral protamine hagedorn (NPH) insulin (8.1%). There was a trend to show a different prescription pattern with basal insulins (as the level of knowledge decreased, the prescription of mixed and NPH insulins increased). More than one-third (35.1%) of primary care physicians did not know more complex patterns of treatment with insulins.

CONCLUSIONS

Only 27% of Primary Care physicians had a high knowledge about treatment with insulins. There was a direct relationship between the level of knowledge about insulins and glycaemic control. It is necessary to improve the knowledge about insulin therapy in order to optimise metabolic control and reduce the risk of complications.