Views of Adolescent Girls on the Use of Implanon in a Public Primary Health Care Clinic in Limpopo Province, South Africa.

2.1. Study Design

A qualitative, explorative, descriptive and contextual research design was used to conduct the study. Through explorative design, the researcher was able to explore the views of adolescent girls regarding the use of Implanon as a birth control method. A descriptive design assisted the participants to describe their views about the use of Implanon as a birth control method based on their experiences and culture, in their own settings. One central question was asked: “What are your views regarding the use of Implanon as a birth control method?” This was followed by questions, which emerged from the discussion, and the questions from the interview guide. Participants expressed their views, which are reflected in words, and quotations used to emphasize various aspects that they described.

2.2. Study Setting

The study was conducted at a primary health care clinic in the Mopani District, Limpopo Province. The clinic is found in the Greater Letaba municipality, Mopani District, Limpopo Province. It is 35 km from Tzaneen and 10km from the Kgapane Hospital. It serves 8 villages.

2.3. Population and Sampling

The study population includes all adolescent girls aged between 17 and 24 wanting Implanon as a contraceptive method, as well as those who had the Implanon implant removed earlier than the anticipated period of 3 years. In addition, adolescent girls who were sexually active and who wished to insert Implanon but were afraid were part of the target population. Non-probability purposive sampling was used to select the participants from the Bolobedu clinic who met the criteria. The study sample size was determined by the information from the participants collected during one-on-one interviews.

2.4. Data Collection

Semi-structured, one-on-one interviews, using an interview guide were used to collect data. Semi-structured, one-on-one interviews encouraged the participants to provide information about their views on the use of Implanon and to respond to probes. To accommodate those who cannot speak or understand English, the interview questions were translated from English to Sepedi. Data were audio recorded, field notes and observations were made. Paraphrasing and probe follow-up questions were asked to facilitate and explore the discussions. Data were collected over a period of two weeks and data saturation was reached with participant number 15. Data saturation is when during data collection no new information is emerging [29, 30]. Data were subsequently transcribed. Documented information was linked with the transcribed data to avoid errors.

2.5. Data Analysis

Data were analyzed using Tesch’s open coding analysis [31]. It involves reading through the transcriptions of each interview to get the meaning, grouping similar topics together, categorizing and summarising the data and describing them in meaningful terms until the themes and sub-themes emerged.

2.6. Trustworthiness

Trustworthiness was ensured through the following: credibility, transferability, conformability, dependability. Credibility was ensured through prolonged engagement in the study field in order to capture the realities [31]. Dependability, which refers to the consistency of the research findings in qualitative research, was ensured by describing the research method used in the study [31]. Transferability, which refers to whether the findings of the research can be transferred from one specific situation to others, was ensured by using a purposive sampling technique [31]. To ensure conformability, copies of the verbatim scripts, field notes, and protocol were sent to an independent coder for analysis.

4.1. Experiences of Adolescent Girls of the Use of Implanon

The study reveals that adolescents experience several side effects when they are on Implanon. These include weight gain, irregular menses, and some complains of weight loss. The study also found that the side effects differ from individual to individual, with irregular bleeding being the most common side effect mentioned. These findings are supported by different studies, which report that most women discontinued Implanon because of emotional liability, weight gain, depression, acne. However, while some discontinue Implanon because of the side effects, some discontinued for no apparent reason [32-34]. Lack of effective treatment of irregular bleeding has been outlined as the primary justification for the early removal of Implanon amongst adolescents [35]. Nevertheless, the study carried out by Patel indicates that girls who experience hemorrhage patterns discontinue the implant partly because they were not properly counselled prior to and post insertion [35].

The study also reveals the knowledge gap about Implanon and how it works. Moreover, the lack of knowledge contributes to the low uptake of adolescent girls of Implanon. The study of Elsenburg et al. reveals that women using short-acting contraceptives, such as pills, knew little about the use and effectiveness of the long-acting contraceptives [36]. In contrast, some adolescents knew about the use of Implanon. They describe Implanon as one of the most effective contraception methods as it means that they do not have to visit clinics frequently because it protects them from falling pregnant for up to 3 years. Additionally, they said Implanon enables them to plan for their future and finish their schooling without worrying about an unplanned pregnancy. Similar results in a literature review study reveal that women like the implant as it has long-term benefits for family planning for them as individuals and their families [37].

The adolescent girls who might like to use Implanon were afraid because of the myths and the presumed experiences of the previous users. They alleged that they had heard that Implanon might get lost in their bodies which might result in an unplanned pregnancy, regarding and that the arm might swell while doing household chores. Similar to the current findings, previous studies also reveal that there are rumors and misconceptions specifically on the side-effects and effectiveness of Implanon in preventing pregnancy [38-42] Merck, the manufacturer of Nexplanon, notes that reported pregnancies amongst implant users have been primarily due to unrecognized pregnancies at the time of insertion or failure to insert the device properly [35]. In a similar context to this study, an informal investigation conducted by the Bhekisisa Centre for Health Journalism in SA, Mpumalanga reports that it was rumoured that poor outcomes of the use of Implanon could also be because of poor training of nurses, which has led to severe reactions of girls using new contraceptive devices [43,44]. Furthermore, it also documents that in Mpumalanga Vukuzahke clinic nurses are no longer inserting Implanon but only removing them [45]. Consequently, the reported pregnancies could be associated with the following factors, which might contraindicate Implanon use: epilepsy, infectious diseases, such as pulmonary tuberculosis, antiretroviral medication, poor screening and different lifestyle factors like abuse and alcohol consumption [46].

Participants on ARV’s were disappointed because health professionals informed them that the Implanon would not suit them. One participant also believed she had conceived a few weeks after the insertion of Implanon because of the use of ARVs. According to the clinical guidelines in South Africa, Implanon is a progestogen that has several interactions with certain drugs especially in women who are HIV positive. Although the use of condoms is crucial, antiretroviral therapy can lead to drug interactions and modify the efficacy of hormonal contraception. Implants should be used with caution in patients on Efavirenz [47]. Research in South Africa confirms that nurses have strong preferences about the methods that are appropriate for women, especially those who are HIV-positive, unmarried, and/ or young [48, 49]. However, in the study carried out on the interactions between hormonal contraception and antiretroviral therapy, even though there were several case reports of contraceptive disappointments from women taking Efavirenz, there were no actual data indicating low efficacy of the implant while co-administrated with HAART [50]. Furthermore, it was recommended that pending the proven data for a good understanding of the interaction of medications. Implanon should remain accessible to women living with HIV. Health care professionals should counsel HIV-positive women wishing to use Implanon as a contraceptive about the importance of dual contraception [51, 52]. In contrast, in Kenya, information from roughly 25 000 HIV-positive women using the implant and EFV primarily based ART had three times the possibility of becoming pregnant than women using nevirapine-based ART [44]. Authors in combined information from seven African countries who found minimized effectiveness among women using EFV-based ART and the implant [53] have supported this.

4.2. Factors Related to Health Professionals and Parents in Relation to the Insertion of Implanon

The study results indicate that adolescents experience challenges concerning informed consent and confidentiality from health care professionals. This was evidenced by adolescent girls who stated that they did not have freedom of choice as to the kind of contraception method they wanted to use. They stated that their parents and health care professionals were the ones who chose contraceptives for them. In South Africa, the Children’s Act [54] outlines that contraception may be supplied to children on request, without parent permission; from the age of 12 and further that, they are also entitled to confidentiality. Adolescents should utilize contraceptive implants confidentially to prevent parental interference and to improve adherence rates [55, 56].

The world movement that supports the rights of women and girls to choose freely for themselves about how many children they want to have, states that it is of great importance to defending the human rights for women and girls [57]. Additionally, the movement further emphasizes that there should be policies and mechanisms to confirm informed selection from a broad range of high quality, safe, effective, acceptable and reasonable contraceptive methods; fairness and the assurance that women and girls are enlightened and not coerced in any way [58]. However, arguments have been raised that young girls are still growing and developing and may not really be able to know clearly and make educated calls about something as important as contraception. They may also be unaware of the potential consequences of their actions. They should be able to debate the issue in an honest way with a parent before making a decision [59].

Poor quality training of nurses on the insertion and removal of Implanon plays a role in the low uptake of Implanon insertion. Participants reported that they did want to have Implanon inserted but every time when they went to the clinic health care professionals turned them away saying they were not trained to insert Implanon. In a qualitative study on understanding the low uptake of long-acting reversible contraception by young women in Australia, it was found that health care professionals had difficulty in accessing long-acting reversible training and, for those who received training, there was little support or follow-up. This made it difficult for them to maintain competency in inserting the long-acting reversible contraception [60]. In South Africa, the Deputy Director of the Department of Health has openly admitted that Implanon education provided to the health professionals might not be adequate, resulting in counselling services which might not be up to standard [45].

Adolescent girls who removed the Implanon before 3 years indicated that if they had given insertion proper consideration beforehand, they would have opted for other contraceptives. The results are in line with the study, which was conducted in the rural area of Tigray Region, Northern Ethiopia, exploring the prevalence and predictors of Implanon utilization among women of reproductive age. The study discovered that most women had inappropriate information about Implanon and recommend that well-being extension workers and other health professionals should offer proper counseling and education about Implanon and other contraceptives [52]. A previous literature review study on the barriers to fertility regulation report that misinformation about contraceptive methods, health issues, language challenges, and health care provider biases are the most common barriers to the initial uptake of Implanon [61]. The SA contraception and fertility planning policy and services outline that women ought to have access to “accurate, unbiased information concerning all offered methods of contraception so that they can make informed decisions subject to meeting relevant medical eligibility criteria and availability [62]. It is extremely important that adolescents in search of contraception are given all of the relevant facts prior to the insertion of an implant, and also that health professionals consider their approach and the environment in which counselling is provided [57]. Furthermore, rich and relevant information will enable clients the time to independently study and reflect on whether or not they wish the implant to be inserted [57, 63]. Considering the high usage of technology of adolescents [64-66] it has been documented that health care professionals should consider the use of novel approaches and technologies such as interactive, internet-based sources of information, text message reminders for renewal as well as pamphlets for improving women’s understanding on how various methods work. This might improve the method uptake and continue to improve knowledge and compliance.

Of note, a study across many Sub-Saharan African countries emphasizes the importance of competency-based coaching on Implanon. The content should include the side effects, management, and regular necessary refresher courses and mentorship should be considered [67]. Further, it has been documented that these efforts would boost the self-confidence of health professional in the insertion and removal of implants. Furthermore, during follow-up training, it was observed that none of the trained health professionals refused to remove the implants [68, 69].