Caregivers’ Perception on Adolescents’ Access on, Use of, and Support Required to Prevent Unwanted Pregnancies in Lesotho
Abstract
Background:
Usage of hormonal or barrier contraception by adolescents is challenging for most adolescents. The study revealed new evidence of caregivers’ support to adolescents on access and effective contraception use to prevent unwanted pregnancies in k.w. There is a need for adolescents’ user-friendly services, supportive supervision, accommodative cultural and religious practices, and the promotion of independent decisions.
Objectives:
To explore and describe caregivers’ perceptions of access (1) and the use of (2) contraception for adolescents in Lesotho and to explore and describe caregivers’ perception of types of support needed for adolescents to prevent unwanted pregnancies in Lesotho (3).
Methods:
A qualitative explorative, descriptive, and contextual design. Purposive sampling caregivers of adolescents in a government primary health care facility with the highest outpatient number in Maseru district, Lesotho. Five focus groups with six participants each, which included (N=30) participants, were conducted using an interview schedule. Data were analysed using Creswell’s six steps of data analysis with the assistance of a co-coder.
Results:
Three categories emerged, namely (1) access to contraception by adolescents, (2) use of contraception by adolescents, (3) and support to prevent unwanted pregnancies with respective themes and sub-themes emerged.
Conclusion:
Contraception use among adolescents is challenging. Adolescents’ caregivers disclosed being unskilled to discuss sexuality due to their cultural and religious background. Basic sexuality education has been included in the school curriculum. Service providers’ attitudes and rigid health services contribute to the limited access to contraception for adolescents.
1. INTRODUCTION
Globally, the use of contraception is one of the pillars of preventing unwanted adolescent pregnancies [1]. Using contraception by adolescents, whether hormonal or barrier methods, seem to be challenging for most adolescents due to several factors, including accessibility either from home, schools, or health facilities [2]. Factors that limit contraception access range from personal factors such as limited knowledge, fear of side effects, low self-esteem, and lack of finances to attend Primary Health Care (PHC) facilities and family-related factors such as poor parent-child communication on sexuality, parents’ negative attitudes on sexual and reproductive health (SRH) for adolescents. Other factors such as gender, cultural and religious norms, and health system factors which includes lack of privacy, compromised confidentiality, stockouts, shortage of skilled trained staff, and judgemental attitude of service providers, also affect contraception seeking and usage [3] also play an important role. Adolescents do not have access to information needed to fulfill their SRH rights [4].
Adolescents represent one-fifth of the world population [1]. Therefore, scaling up access to contraception and the need for contraception can contribute to the 2030 agenda for sustainable development goals [4]. Some adolescents fail to use contraception due to several factors like limited information, fear of side effects, and service provider attitude [1, 5]. On the contrary, others do not seek or use contraception to avoid parental judgment [6].
When an adolescent fall pregnant, both partners, especially the female, are challenged with decisions such as abortions due to unwanted pregnancies [7], which in turn can cause maternal complications. Abortion is a serious challenge in Lesotho because it is not legal [8, 9]. In Lesotho, some adolescents with unwanted pregnancies seek safe abortion services in neighboring countries such as South Africa if they have money; otherwise, they opt for unsafe ‘backstreet’ abortions [9, 10]. Thereafter, they also deal with the stigma related to abortion and future contraception use [10]. A fact remains that the younger the adolescent, the more risk is associated with unwanted pregnancy [11]. Given the situation, the Ministry of Education in Lesotho developed an extra curriculum on risk reduction for adolescents to empower them on sexuality issues such as the comprehensive sexual education fact series [12].
Abstinence is effective in pregnancy and Sexually Transmitted Infections (STIs) prevention, and it forms an integral part of counselling on contraception [13]. Although abstinence is shown to be effective if applied, this is not always viable in practice due to various factors such as peer pressure. However, adolescents report that cultural and religious caregivers’ reactions and attitudes regarding SRH make them uncomfortable [6]. Caregivers mostly insist on abstinence as the only available contraception option for adolescents [14]. This statement is supported by a South African study that revealed that some challenges cited by adolescents on contraception access and use are primarily a lack of support from their caregivers, including their sexual partners [15]. This problem is even worsened as adolescents are reported to face challenges most of the time; they attend health facilities for contraception [16]. However, healthcare services are in the key position to try and address this by providing adolescent-friendly contraception services [17]. In controversy, Family Planning High-Impact Practices also mentioned that countries that have tried user-friendly adolescent services where they are not mixed with adults found the model challenging to sustain due to limited resources like human resources and irrational deployment for utilisation of specialised services [17]. The world of technology has promoted advocacy for adolescents using social media to facilitate service provider adolescent-tailored information, including contraception access [18]. However, despite advanced technology and research, the topic of SRH remains taboo in most households, [3]. This is concerning as adolescents need support in accessing and using contraception during their transition to adulthood [17].
In Lesotho, education and health policy do not contradict each other however, the issue of contraception and pregnancy at school is not discussed [7]. The policy supports the inclusion of life skill education into the school curriculum, but the practice is neither universal nor mandatory due to different religious and cultural beliefs [12]. Acknowledge the effect of schooling as there has been a significant increase in adolescent pregnancies, which can be attributed to the coronavirus pandemic beginning in 2019 (COVID-19), which negatively impacted health and education [19]. Despite knowledge, access, use, and support, there is a gap in the current literature regarding caregivers’ perceptions of contraception access and use among adolescents [20].
In South Africa, there has been a challenge to contraception access in the public sector for the past five (5) years [19], which could be the same for Lesotho, which is also a low-and middle-income country. This was eminent as, in 2021, several media reported an escalation in adolescent pregnancies [19]. This can be attributed to an alarming increase in adolescent pregnancy [21]. Adolescents confirm that the strategies in place are still valid and relevant [2]. However, the manner of implementation of these strategies needs modification and scaling up considering the following areas: suitable adolescents’ user-friendly services, availability of all contraception methods, an increase of outlet services like outreaches, shops, pharmacies, supportive laws and policies and continuous research to inform policy [1].
Contraception access and use must be availed beyond government and public health facilities, as most adolescents prefer pharmacies [17]. The importance of providing contraception at PHC facilities and supplementation by using outreach services is of great importance [17]. Although additional outreach services can be challenging, youth centres and corners bring adolescents together and provide a conducive environment for small-group learning and information-sharing activities [12]. It is, therefore, evident that various support strategies are necessary to increase access to and use of contraception as one strategy cannot fit all; hence several approaches are required [22].
On the other hand, adolescents feel that caregivers such as parents do not encourage them to use contraception [23, 24]. Some feel that parents put their children at risk of being rejected if they are found to be using contraception, whilst some schools can expel adolescents if they are found using contraception [10]. As a result, adolescents have various changes; hence caregivers must have an appropriate way to support them.
On the other hand, adolescents are a vulnerable population with different needs at the ages of 10-19 despite their marital status, number of pregnancies, Human Immunodeficiency Virus (HIV) status, and those living with disabilities [25]. Other studies revealed that married or cohabiting heterosexual adolescents mostly use contraception more than those not in a union (not married) [26]. Those in union freely use government facilities to access contraception, while those not in union prefer pharmacies [5].
2. MATERIALS AND METHODS
2.1. Design
A qualitative, exploratory, descriptive, and contextual design was followed, to get an in-depth understanding of the caregivers’ perception of adolescents’ access to, use of, and support required to prevent unwanted pregnancies in Lesotho [27].
2.2. Population and Sampling
The population included caregivers in a PHC facility in Maseru, Lesotho. The caregivers were purposively selected. The inclusion criteria comprised of adolescents’ parents, grandparents, aunts, siblings, and caretakers willing to voluntarily consent to participate and had no objection to being recorded. The exclusion criteria included any person that is not a caregiver of an adolescent who did not want to participate or sign voluntary informed consent. A total of five focus groups consisting of six participants each were done, which included a total of (N=30) participants. Data saturation was reached.
2.3. Data Collection
Participants were recruited via posters in the PHC facility. In 2022 data were collected for three weeks. Willing participants participated in focus groups using an interview schedule. A private multipurpose hall at the PHC facility was used for each focus group interview. The interviews lasted 60-90 minutes and were recorded with an audio recorder. The questions in an interview schedule included the following: questions: What is the first thing that comes to mind when you hear the phrase SRH service provision and adolescents? How can SRH service provision to adolescents be facilitated? Do you think they have access to contraception services and if not, why? What type of contraception do you think adolescents use? Can you give examples? Where, do you think, do they seek contraception services? If we focus on health care services, what type of barriers prevents adolescents from going to PHC facilities for contraception? What do you think can be done by healthcare givers or schools to support adolescents to access contraception services? What do you think is the consequence of inaccessibility to contraception for adolescents? What are the advantages and disadvantages of adolescents using contraception? What are your perceptions of adolescents accessing contraception? What are your cultural and/or religious beliefs regarding the use of contraception by adolescents? What type of support do you think from a personal perspective as caregivers can be given to adolescents? Can you specifically elaborate on the following support for adolescents to use contraception: health services delivery, school, psychological, psychosocial, cultural, religious, and financial support? Fieldnotes were taken after each focus group interview.
2.4. Data Analysis
Data were analysed using Creswell’s six steps of qualitative data analysis. Step 1: data were organised by transcribing the interviews verbatim and coding was done with the assistance of a co-coder. Step 2: Data were re-checked by obtaining a general sense of the participants' viewpoints. During step 3 (coding) and step 4 (developing themes), data were organised into categories, themes, and sub-themes. Step 5 included the re-presentation and description of categories, themes, and sub-themes using quotes in table format. In step 6 findings were interpreted [28]. After completion of the data analysis, a consensus discussion was held to ensure that the categories, themes, and sub-themes that emerged during the focus groups were a true reflection.
2.5. Measures to Ensure Trustworthiness
Four epistemological standards do trustworthiness: truthfulness, applicability, consistency, and neutrality trustworthiness are done in four epistemological standards: truthfulness, applicability, consistency, and neutrality [28, 29]. This study met all the criteria for trustworthiness. The first author was engaged during data collection, which denotes truthfulness. It is applicable because the population size was limited. However, new findings are emerging from the focus group, which indicates that the findings can be generalised and have indicability. Consistency was ensured by using the interview schedule throughout the semi-structured focus group interviews. The results have been presented neutrally without biases. And the study results are authentic because they convey the perception of adolescents’ caregivers regarding access to, use of, and support for adolescents’ contraception to prevent unwanted pregnancies in Lesotho.
3. RESULTS
All the participants (N=30; 100%) were Basotho caregivers, and their mother tongue was Sesotho. The majority of the participants were over the age of 40 years (n=15; 50%), followed by the age group 31-39 years (n=10; 33%), age group 26-30 years (n=2; 7%), and lastly, age group 21-25 (n=3; 10%). Most participants stayed in an urban area (n=11; 37%), semi-urban (n=9; 30%), and rural (n=10; 33%). The level of the participants’ education was mostly secondary (n=11; 37%) followed by tertiary (n=10; 33%), primary (n=7; 23%), with (n=2; 7%) with no education. Most participants were civil servants (n= 7; 23%), followed by self-employment (n=6; 20%), industrial workers (n=5; 17%), personal household work (n=4; 13%), part-time work (n=3; 10%), pensioners (n=3; 10%) and domestic workers (N=2; 7%).
The categories, themes, and sub-themes, including the quotes of the participants on the perceptions of caregivers on the access to and use of types of support needed to use contraception and prevent unwanted pregnancies in Lesotho, are tabulated in Table 1.
From the results of the Caregivers’ perception of adolescents’ access to, use of, and support required to prevent unwanted pregnancies in Lesotho, three categories with their respective themes and sub-themes emerged (Table 1).
3.1. Category 1: Access to Contraception by Adolescents
Five themes cited by the participants included: persons influencing contraception-seeking behaviour, consequences of inaccessibility, contraception method preferences, accessible locations for contraception, and barriers to PHC facilities.
3.1.1. Theme 1.1 Persons Influencing Contraception-seeking Behaviour
The provision of dual-method contraception (hormonal methods and condoms) is the most pivotal to preventing unwanted teenage pregnancy and protecting against STIs. Adolescents’ caregivers reported peers, boyfriends, sugar daddies, parents, teachers, other caregivers, and spiritual leaders influencing adolescents’ contraception-seeking behaviour.
| Categories | Themes | Sub-themes | Quotes |
|
1. Access to contraception by adolescents |
1.1 Persons influencing contraception-seeking behaviour | Peers |
‘Our children rely on their friends [peers] for health issues’ (Participant [PAT]4, 42-year-old, female, Focus Group [FG]1) ‘Adolescence is a period for peak friendship therefore whatever is shared on a friendly basis becomes easier to follow including getting contraception’ (PAT1, 49-year-old, female, FG4) |
| Boyfriends |
‘Our girls listen to their boyfriends who happen to be their age mates’ (PAT1, 36-year-old, female, FG3) ‘Boyfriends are dictating to girls what they should do for contraception’ (PAT4, 26-year-old, female FG5) |
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| Sugar daddies |
‘There is also this issue of adults [called sugar daddies] who hook our youth with a luxurious material like money, cell phones, clothes, etc. that cannot be afforded by parents’ (PAT6, 32-year-old, female, FG4) ‘Sugar daddies and sugar mummies are filthy parents who destroy our adolescents’ future in exchange for luxurious goods and money hence they believe in them’ (PAT2, 42-year-old, female, FG2) |
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| Parents |
‘If we inform our children properly, they believe in us as their role model’ (PAT4, 47-year-old, female, FG5) ‘I wish it could be easy for all of us to encourage our adolescents openly to access contraception as it can be the most effective way for them to prevent unwanted pregnancies (PAT3, 52-years-old, female, FG2) |
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| Teachers |
‘Youth believes in what is said by their teachers than anyone’ (PAT3, 50-year-old, male, FG1) ‘Teachers are very good communicators who can talk about everything without being shy like us hence they can influence them easily to access contraception’ (PAT5, 32-year-old, female, FG 4) |
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| Other caregivers |
‘Youths who stayed at the orphanages or save homes believe on the caretaker’s guidance’ (PAT5, 49-year-old, female, FG3) ‘Orphaned adolescents are mainly guided by their relatives who are rendering care to them. (PAT1, 33-years-old, female, FG4) |
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| Spiritual leaders | ‘Some adolescents are still obedient enough to be guided by the spiritual healers of their chosen congregation’ (PAT2, 44-year-old, female, FG4) | ||
| 1.2 Consequences of Inaccessibility |
Unwanted pregnancies |
‘Youth like sex too much before they mature and they end up pregnant unintentionally due to contraception which is not easily accessible (PAT4, 63-year-old, female, FG1) ‘Unwanted pregnancy seems to be a cup of tea for adolescents these days as they engage in unprotected sex without critically thinking’ (PAT5, 49-year-old, female, FG2) |
|
| Illegal abortions |
‘When they find out that they are pregnant, they become confused and opt for back street abortion coz it is illegal in this country, and most of the time the perforate uteruses or they become septic’ (PAT1, 36-year-old, female, FG3) ‘I advocate for abortion to be legalised’ (PAT3, 50-year-old, female, FG5) |
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| Maternal complications |
‘Adolescents engage in unprotected sex that exposes them to the difficult situation associated with labour like caesarean delivery’ (PAT1, 55-year-old, female, FG2) ‘Early pregnancies expose adolescents to the raptured uterus because their bodies are still immature’ (PAT4, 52-year-old, female, FG3) |
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| Unpreparedness for parenthood |
‘Unwanted pregnancies affect the adolescent and the whole family as the adolescent does not want to play an adult role at their age’ (PAT5, 49-year-old, female, FG3) ‘Parenting is not so easy, adolescents cannot manage to be ones’ (PAT2, 62-years-old, female, FG5) |
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| Family blame and stigma | ‘Our families are blamed by the neighbours and villagers that we have the bad skills to raise children’ (PAT3, 50-year-old, male, FG1) | ||
| Abandonment of infant and/or children | ‘They [adolescents] ended up having unwanted kids and throw them away because they are not yet ready to care for other babies while they are babies’ themselves’ (PAT2, 34-year-old, female, FG2) | ||
| Malnutrition of infants and/or children | ‘Adolescents do not have the patience to feed kids resulting in malnutrition because they fail to raise children as they are children themselves’ (PAT4, 28-year-old, female, FG1) | ||
| Increased school dropout | ‘They [adolescents] drop out of school to care for their babies as we do not have money for formula feeding for them to continue schooling while we take care of the baby’ (PAT6, 45-year-old, female, FG3) | ||
| Depression | They sometimes end up depressed when they see their age mates schooling, and they resort to drug abuse or even suicide’ (PAT5, 29-year-old, female, FG2) | ||
| Drug abuse | ‘Adolescents with unwanted pregnancy or baby become isolated and lonely and sometimes resort to misuse of drugs and substances’ (PAT3, 50-year-old, male, FG1) | ||
| Poor literacy rate | ‘Our adolescents ended up futureless as they add to the national statistic that did not complete schooling’ (PAT2, 52-year-old, female, FG4) | ||
| Low education levels result in poverty due to poor-employability | ‘There is a high competition for employment these days, and the educated adolescents stand a better chance for employment than the uneducated one’ (PAT2, 33-year-old, female, FG4) | ||
| The increased infant mortality rate due to poor care by adolescents | ‘Children who are taken care of by the youth have less likelihood to survive due to the poor care as they are always in a hurry’ (PAT2, 30-year-old, female, FG5) | ||
| Increased adolescent maternal mortality due to poor monitored pregnancy | ‘Sometimes they hide pregnancy till delivery exposing them to unmonitored antenatal that may result into the child or both illness and death’ (PAT2, 48-year-old, female, FG3) | ||
| 1.3 Contraception method preferences | Injectables | ‘Adolescents mostly choose injection as a method of contraception because it is not visible and it does not require them to take daily nor visit the facility frequently’ (PAT2, 39-year-old, female, FG4) | |
| Barrier methods | ‘They use condoms easily because they are easy to get, but they dispose of them badly because used condoms are found all over the place’ (PAT3, 28-year-old female, FG2) | ||
| Morning after pill |
‘They usually engage in unwanted, irregular sexual activities due to peer pressure or drugs and they source morning-after pill several times as if it is a regular method’ (PAT5, 30-year-old, female, FG3) ‘Adolescents use no method because they pretend to be innocent before parents, caregivers, and whole villagers’ (PAT4, 27-year-old, female, FG5) ‘Youth want to use the emergency pill as their regular method as they engage in sexual activities unwanted’ frustrating’ (PAT3, 49-year-old, female, FG2) |
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| 1.4 Accessible locations for contraception |
Youth clubs | ‘It is easier for adolescents to buy contraception over the counter at the retail shops or pharmacies than to attend to the health facilities because they don’t want to be seen and they are always in a hurry’ (PAT2, 44-year-old, female, FG4) | |
| Pharmacies | ‘Adolescents like pharmacies as there are no ques and a lot of restrictions like examinations before getting contraception’ (PAT3, 57-year-old, male, FG1) | ||
| Shops | ‘Youths consider counter contraception easy and convenient to get’ (PAT5, 29-year-old female, FG5) | ||
| Peers distributing condoms | ‘Only condoms are available and mostly male ones than female ones, but they are easy to get for adolescents’ (PAT3, 28-year-old, female, FG4) | ||
| Community-level outlets | Most of the time, they lack money because they are not working, and they can access contraception if they are available at the community level under the care of their age made not an adult’ (PAT4, 42-year-old, female, FG2) | ||
| Non-governmental Organizations (NGOs) |
‘Youth do not like to mix with adults for services to avoid humiliation and embarrassment, and therefore they like places like LPPA [Lesotho Planned Parenthood Association], and Dreams near Sefika Shoprite’ (PAT3, 28-year-old, female, FG1) ‘I have no idea about youth areas of interest; I mostly see them at public facilities’ (PAT3, 41-year-old, female, FG4) |
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| 1.5 Barriers to PHC Facilities | Services not tailored for adolescents’ needs | ‘The language that is used at our family planning health facilities is not accommodative of adolescents bearing in mind that they mostly attend English medium school, and their Sesotho vocabulary is very limited’ (PAT3, 28-year-old, female, FG2) | |
| Combining adolescents' and adults’ contraception services | Our youth do not want to be mixed with us as adults because we tend judging them through nasty comments or negative looks’ (PAT5, a 29-year-old, female, FG3) | ||
| Inflexible and unaccommodating service hours | ‘Adolescents normally do not do things on time. They choose uncommon hours may be due to their school schedule or habitually’ (PAT4, 27-year-old, female, FG5) | ||
| Unfriendly health service providers | ‘Most of the time youth complain of the bad attitude of health service providers, especially at the public facilities where services are free’ (PAT2, 26-year-old, female, FG3) | ||
| 2. Use of contraception by adolescents | 2.1 Usage of Contraception by sexually active adolescents | Consistent use | ‘Youth stage is so challenging some use contraception consistently, especially when they are sexually active’ (PAT3, 28-year-old, female, FG4) |
| Inconsistent use | On the other hand, others do not use contraception regularly because they want to trap their partners so that they are forced to live with them by circumstances or by parents’ (PAT2, 48-year-old, female, FG2) | ||
| No use | Some adolescents do not use contraception at all either because they are innocent, careless, or fearful’ (PAT2, 26-year-old, female, FG3) | ||
| 2.2 Advantages of using contraception |
Prevent unwanted pregnancy | ‘Contraceptives prevent pregnancy if effective’ (PAT6, 45-year-old, female, FG5) | |
| School Completion | Contraception protects adolescents to finish school while they continue with sexual activities because they enjoy them so much’ (PAT2, 26-year-old, female, FG4) | ||
| Improve the country’s literacy | ‘If an adolescent is not interrupted with an unwanted pregnancy, she will be educated and add to the count of literacy rate’ (PAT4, 53-year-old, female, FG2) | ||
| Employment | ‘Nowadays employment opportunities are very slim but those who are educated stand a better chance for employability’ (PAT3, 41-year-old, female, FG5) | ||
| Economic growth |
‘The working class, whether formally or self-employed, contribute to economic growth at different scales’ (PAT4, 27-year-old, female, FG2) ‘If many adolescents are educated, they contribute to the whole country’s number of people who can read and write’ (PAT1, 31-year-old, female, FG3) |
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| Matured body for pregnancy and delivery | If adolescents can delay pregnancy until their bodies are mature enough to cope with pregnancy’ (PAT2, 48-year-old, female, FG4) | ||
| Decreased adolescent and infant mortality rate | ‘The youth illness and deaths, as well as their babies, will be less in number’ (PAT2, 67-year-old, female, FG1) | ||
| Poverty eradication | ‘Adolescents who are working are less likely to be affected by poverty than those who are none employed’ (PAT2, 26-year-old, female, FG3) | ||
| Ability to provide for the infant | ‘The working adolescents can be able to provide for the baby much they like to smart themselves clothes, manicure and hair dressing’ (PAT2, 26-year-old, female, FG2) | ||
| Prevent malnutrition of the infant |
‘If the baby is well planned, its nutritional needs will be catered for and will not be malnourished’ (PAT3, 29years old, female, FG5) ‘Malnutrition of infants and/or children due to poor nutritional needs’ (PAT1, 31-year-old female, FG3) |
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| Avoid illegal abortions | ‘If adolescents use contraception properly, they will not become pregnant, and therefore they will not have to abort the foetus’ (PAT4, 53year-old, female, FG4) | ||
| Decrease abandoned children | ‘Using contraception prevents unwanted babies that are thrown away on the street’ (PAT2, 67-year-old, female, FG2) | ||
| Prevent maternal complications (ruptured uterus, sepsis, pregnancy-induced hypertension, etc.) | ‘Adolescents who delay pregnancy till their bodies are mature are less exposed to labour and its challenges like torn uterus’ (PAT6, 45-year-old, female, FG1) | ||
| Prepare adolescents to be ready for parenthood | ‘Delayed pregnancy by adolescents offers the opportunity to be ready for parenting activities’ (PAT2, 67-year-old, female, FG3) | ||
| Prevent parental frustration in taking care of the adolescent’s infant. |
‘As parents, we do not like to be burdened with unwanted children. We just assist our adolescents because we don’t want them to kill those babies or drink unsafe stuff that may be poisonous and kill them’ (PAT1, 31-year-old, female, FG4) ‘Some of us cannot even remember how to care for the newborn properly. Having to care for the unwanted baby would be so frustrating’ (PAT2, 61-year-old, female, FG2) |
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| Keep the family from blame and stigma of poor upbringing | ‘We all know village life. Once your child has an unwanted baby, everyone blames you for the poor upbringing of children; hence they are going all over the place to make’ (PAT3, a 50-year-old, male, FG1) | ||
| Avoid depression | ‘Having to live parenthood life while you are still young is so much frustrating and depressing for the adolescent’ (PAT2, 6-year-old, female, FG2) | ||
| Prevent drug abuse due to stress | ‘When an adolescent finds herself with an unwanted child, all other plans change, and the adolescent may fill stressed and may resort to using drugs and substances negatively’ (PAT6, 28-year-old, female, FG5) | ||
| 2.3 Disadvantages of using contraception | Enhanced promiscuity | ‘I wish adolescents could be injected with contraception without knowing so that they do not go around having sex with everybody because they know they cannot be pregnant’ (PAT3, 41-year-old, female, FG4) | |
| Cultural stigmatization of adolescent immorality. | ‘Our cultural beliefs and norms influenced the way we do things, and we cannot take it positively for an adolescent to use contraception openly’ (PAT3, a 50-year-old, male, FG1) | ||
| Infertility |
‘If Adolescents started to use contraception early, they become infertile while they are married and need to bear children’ (PAT2, 61-year-old female, FG2) ‘Culturally, infertility is not acceptable, and most of the time, the blame is left with the female. An adolescent who is believed to use contraception is anticipated to be infertile in the near future because there is a belief that each sexual contact results in a baby, so if one uses contraception, she is killing babies’ (PAT5, 44-year-old, female, FG4) |
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| Risk of careless sexual behaviour resulting in STIs and HIV | ‘Adolescents, if they ca know that they are protected from pregnancy, they will forget about infectious diseases like STI and HIV’ (PAT3, 41-year-old, female, FG3) | ||
| 2.4 Caregivers’ Beliefs |
Judgmental | ‘Personally, even if I don’t voice it, I become shocked if I see an adolescent using contraception it happens automatically’ (PAT4, 51-year-old female, FG5) | |
| Taboo | ‘Culturally it is not acceptable for adolescents to engage in sexual activity before marriage and sourcing contraception would disclose the secret that they have already started’ (PAT3, a 50-year-old, male, FG1) | ||
| Immorality | ‘If villages or relatives can know that an adolescent is using contraception, they will label her as a loose child [immorality] who should not mix with their children and her chances of getting married in her area is compromised’ (PAT6, 42-year-old, female, FG2) | ||
| Adolescent body will lose tone and become less attractive |
‘There is also a belief that if some adolescents use contraception, the muscle tone of their body loose firmness’ (PAT4,53-year-old, female, FG4) ‘I am the witness to that it is true, adolescents who are using contraception have spare meats and floppy breasts’ (PAT3, 45-year-old, female, FG5) |
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| Need for Adolescents’ contraception |
‘Much as we can ignore the truth, adolescents do need contraception rather than having unintended, unwanted pregnancy because it has so many challenges that do not only affect the adolescent but the whole family and village’ (PAT5, 47-year-old, female, FG3) ‘Whether we like it or not, there are no reverse adolescents need contraception to prevent unwanted pregnancy (PAT, 31-year-old, female, FG1) |
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| 2.5 Cultural beliefs |
Culturally immoral | ‘We grew up in a culture that discourages sex before marriage, but it’s not like it is not happening. Unfortunately, the results of that dishonesty are not easy to tolerate (PAT6, a 58-years old, female, FG4) | |
| Stigmatization | ‘I don’t like a daughter-in-law with baby symmetry on the waist’ (PAT2, 67-year-old, female, FG3) | ||
| Poor value | ‘An adolescent who uses contraception or has a child before marriage is of less value, and her bridal price must be less’ (PAT3, 49-year-old, female, FG5) | ||
| Cultural practices | ‘In the remote areas where we originate before we move to Maseru village girls have several games where elders will be examining them for virginity even without touching them, for example, wearing cultural attire, and we all know it exposes breasts’ (PAT4, 66-year-old, female, FG2) | ||
| 2.6 Religious beliefs |
Against Gods will |
‘God instructed us to live in this world to multiply, so we should not work against his will as it is a sin’ (PAT2, 61-year-old, female, FG4) ‘Muchas I agree that it is against God's will, I don’t think she would like to see us suffering, and she will bless anything that makes us survive’ (PAT1, 45-year-old, female, FG1) ‘Thou shall not kill’ We can advocate for anything else except the thing that is against human nature (PAT4, 50-year-old, female, FG4) |
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| 3. Support to prevent unwanted pregnancies | 3.1 Caregivers’ support |
Social support |
‘An adolescent is still a child that needs to be supported with continuous encouragement regardless of whether she is culturally or religiously complying’ (PAT6, 54-year-old, female, FG3) ‘We should not guide our adolescents only but let them decide on the sexuality issues affecting them’ (PAT1, a 31-year-old, female, FG2) |
| Information Sharing |
‘Parents and caregivers must learn to befriend their children and discuss sexuality with their children [SRH information]’ (PAT5, 43-year-old, female, FG5) ‘There is a WhatsApp application at the Ministry of Health facilities like this one, supported by Mothers to Mothers, which has a drop-down menu to choose the topic that you wish to know more about in relation to sexuality and reproductive health’ (PAT3, 30-year-old, female, FG4) |
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| Financial support for transport to health services | ‘As parents, we have to give money to adolescents for accessing contraception because they will either become pregnant if not getting contraception and they will opt for back street abortion that may eventually lead to death or permanent disability (PAT2, 46-year-old, female, FG3) | ||
| Advocacy for dilution of cultural beliefs regarding contraceptive usage | ‘We wish to be skilled enough so that we can convince our local leaders like chiefs, councillors, and the like. We can lobby them by showing them the advantages of using versus disadvantages of using contraception by adolescents’ issues’ (PAT3, 42-year-old, female, FG1) | ||
| 3.2 School support | Strengthen existing life skills curriculum | ‘These kids are already taught life skills in other schools as it is intergraded into the curriculum it is better to strengthen that practice because teachers are bold and skilled to address student on any issues’ (PAT5, 47-year-old, female, FG2) | |
| Provision of school health nurses to provide health education and contraception |
‘Ministry of Health and Education must join hands to promote access and use of contraception by adolescents’ (PAT2, 26-year-old, female, FG3) ‘I think there is a need to have a nurse deployed at every school to cater for student and out-of-school youths surrounding the school with health-related needs’ (PAT4, 41-year-old, female, FG1) |
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| 3.3 Healthcare provider support |
Revive school health services | ‘Health authorities should re-start school health services as they used to be helpful’ (PAT2, 26-year-old, female, FG5) | |
| Social media platforms |
‘Health services used to be conducted at school, but they are no longer done. I think the Ministry of Health should consider the revival of that strategy to compensate for health services “Much as school health may be helpful, some adolescents may fear to attend to school health services because both teachers and health providers show negative attitudes habitually’ (PAT2, 44-year-old, female, FG3) ‘Our youths are too much hooked by social media; therefore, a message from the social media is whar they will consider, so we have to take an advantage of important messages like life skill empowerment’ (PAT6, 28-year-old, female, FG2) |
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| Conduct outreach services | ‘Health facility personnel use to conduct outreaches to the hard to reach the area around their catchment population, and that used to help a lot, especially for accessibility purposes they must be advised to continue that service’ (PAT4, 50-year-old, female, FG1) | ||
| Advocacy for access in churches and community gatherings. |
‘As parents and caregivers, we need to be trained so that we are competent to address religious leaders on issues related to sexuality and contraception amongst adolescents’ (PAT5, 30-year-old, female, FG5) ‘I truly cannot talk about adolescents contraception in church, God can punish me’(PAT5, 52-year-old, female, FG4) |
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| Capitalise on health partner resources to improve access |
‘Ministry of Health has several developing and implementing partners which can be maximised to support adolescents with sexuality education and provision of contraception’ (PAT2, 31-year-old, female, FG2) ‘I have no idea regarding the issue of Ministry of Health Partners’ (PAT4, 54-year-old, female, FG1) |
3.1.2. Theme 1.2 Consequences of Inaccessibility
Caregivers reported consequences of contraception inaccessibility as follows: unwanted pregnancies, illegal abortions, maternal complications, unpreparedness for parenthood, family blame and stigma, abandonment of infant and/or children, malnutrition of infant and/or children, increased school dropout, depression, drug abuse, poor literacy rate, low-education levels resulting in poverty due to poor-employability, increased infant mortality rate due to poor care by adolescents, and increased adolescent maternal mortality due to poor monitored pregnancy.
3.1.3. Theme 1.3 Contraception Method Preferences
Caregivers reported injectables, barrier methods, and morning-after pills as adolescents' preferred methods of contraception.
3.1.4. Theme 1.4 Accessible Locations for Contraception
Youth clubs, pharmacies, shops, and peers distributing condoms at community-level outlets and NGOs are reported by caregivers as to best preferred accessible locations for adolescents to source contraception.
3.1.5. Theme 1.5 Barriers to PHC Facilities
Participants mentioned several barriers for adolescents to access contraception at PHC facilities: services not tailored to adolescents’ needs, combining adolescents' and adults’ contraception services, inflexible and unaccommodating service hours, and unfriendly health service providers.
3.2. Category 2: Use of Contraception by Adolescents
There are six themes cited by participants under the use of contraception by adolescents, namely usage of contraception by sexually active adolescents, the advantages of using contraception, the disadvantage of using contraception, and caregivers' beliefs, including cultural and religious beliefs.
3.2.1. Theme 2.1 Usage of Contraception by Sexually Active Adolescents
Sexually active adolescents are reported to have different behavioural patterns when using contraception; some have consistent use, some have inconsistent use, and others do not use contraception.
3.2.2. Theme 2.2 Advantages of Using Contraception
Caregivers reported the advantages of using contraception: preventing unwanted pregnancy, offering the opportunity to complete school, improving the country’s literacy rate, creating chances for employment, and adolescents can contribute to economic growth. Adolescents’ bodies are mature for pregnancy and delivery. Using contraception also decreases adolescent and infant mortality and eradicates poverty. Adolescents can provide for their infants, which includes the prevention of malnutrition. The high number of illegal abortions will be avoided, and the number of abandoned children will decrease. Maternal complications like ruptured uterus, sepsis, pregnancy-induced hypertension, etc., will be prevented. Adolescents will be prepared and ready for parenthood, and prevention of parents’ frustration take care of the adolescents’ infant. Families of pregnant adolescents will be kept from blame and stigma of poor upbringing by the community. Depression will possibly be avoided, and the use of drugs due to stress will be minimized.
3.2.3. Theme 2.3 Disadvantages of Using Contraception
According to the caregivers using contraception by adolescents can enhance promiscuity. Moreover, culturally adolescents are stigmatized for immorality. They also believe that contraception use amongst adolescents may result in them being infertile in the future when they are married. There is also a fear that adolescents are at risk of careless sexual behaviour resulting in STIs and HIV.
3.2.4. Theme 2.4 Caregivers’ Beliefs
Caregivers reported that it is automatic to be judgmental of adolescents who use contraception. They also consider contraception use as a taboo. Contraception usage amongst adolescents is also believed to cause immorality, and they also believe that the adolescent body will lose tone and become less attractive. However, besides these beliefs, caregivers still realize the need for adolescents to use contraception.
3.3. Category 3: Support to Prevent Unwanted Pregnancies
The participants cited three themes: caregivers’ support, school support, and healthcare provider support.
3.3.1. Theme 3.1 Caregivers’ Support
Participants believe that there is a need for social support to adolescents through information sharing on SRH, financially supporting them to visit a health service, and advocating for the dilution of cultural beliefs regarding contraception usage by adolescents.
3.3.2. Theme 3.2 School Support
Participants believe that schools should strengthen existing life skills curricula. They also revealed a need for the provision of school health nurses to assist with health education and contraception.
3.3.3. Theme 3.3 Healthcare Provider Support
Caregivers believe that health authorities should consider school health program revival, including social media platforms and conducting outreach services. They also mentioned a need for advocates for adolescents to access contraception in churches and community gatherings and capitalize on health partner services to improve access and use of contraception.
4. DISCUSSION
Access to contraception by adolescents, whether hormonal or barrier methods of contraception reduces the risk of pregnancy [17, 31-33] and STIs transmission [34-37]. However, internal, and external (male and female) condoms and dental dams provide protection against STIs. Other studies agreed with adolescents’ caregivers that various persons influence contraception-seeking behaviour, such as peers [8, 38, 39] boyfriends [11, 40], sugar daddies (older partners) engaging in sexual activities in exchange for material items [41], money or any other incentive) parents [42-45], teachers [46-48], other caregivers [11, 49, 50], and spiritual leaders [51].
The most reliable means to prevent adolescent pregnancy [31, 33, 52, 53] include access to contraception. Adolescents received encouragement from their peers and caregivers [14, 38, 39]. However, in the 21st century, it is evident that social media platforms can also play an important part which was found in this study. The literature supports that boyfriends are also some of the main influencers of adolescents to assess contraceptives and have an impact on sexual practices, contraceptive use, as well as initiation of communication and discussion of sexuality issues [54, 55]. Other studies also reported that sugar daddies in exchange for items or goods known, with whom it is sometimes challenging to negotiate protected sexual intercourse [41, 56]. Literature also supports that parents positively influence decision-making and usage of contraceptives [42-45]. The authors believe that parents and/or caregivers are reliable sources to give health information that empowers adolescents on how to make and handle SRH challenges. This study found that teachers also have a fundamental role in the contraception-seeking behaviour of adolescents because teachers are more comfortable talking about SRH [46-48]. In this study, spiritual leaders also influence the contraception-seeking behaviour of adolescents, which is supported in literature because religion is generally taken seriously in Africa, especially Lesotho, and therefore spiritual and/or religious leaders play a crucial role in guiding adolescents on SRH [51].
Consequences of inaccessibility found in this study were all found in other studies, which included unwanted pregnancies [5] and illegal abortions [10, 57, 58] and in Lesotho specifically that 2.0 -4.4 million adolescents opt for mostly unsafe abortion yearly, which results in maternal complications such as pregnancy-induced hypertension, anaemia, gestational diabetes, birth trauma, prematurity, low birth weight infant [57, 59, 60] and high mortality rate [61]. Many adolescents are not prepared for parenthood [62], which results in abandonment [63] and malnutrition of infants and/or children [64]. Other studies also confirmed that adolescents can’t always meet nutritional and physiological needs and abandon the infant and/or child [64]. As found in this study, the adolescent's family is often blamed and stigmatized. As found in this study, adolescent pregnancy also increases school dropout [65] and depression. This is confirmed in the literature stating that adolescent pregnancy increases the chances of abandonment due to several factors like the high magnitude of poverty and depression [63]. Other factors include drug abuse [66] which is also caused by a lack of having a good future due to poor literacy rate and poor education levels [67, 68], which inevitably mostly results in poverty [69] because these adolescents have poor employability [70]. This was also found by another author that supports the statement that childbearing poses a threat to adolescents’ educational fulfilment as they must drop out of school to look after the infants. Participants reported extreme poverty that brought about adolescents' unwanted pregnancies [67]. Another author added that significantly improved health literacy is required for adolescents as lower literacy increases the likelihood of less usage of health services, including contraception [68]. This is concerning as unwanted pregnancy can cause an increase in infant mortality rate due to poor self-care by adolescents and increased adolescent mortality due to poorly monitored pregnancy. When adolescents do not seek health care for serious challenges on reproductive health issues such as adolescent reproductive pregnancy, it becomes an extra burden to the family. Caregivers reported that adolescent with an unplanned child is not always employable despite the high competition and the fact that they do not have relevant qualifications for the job.
Caregivers reported injectables, barrier methods, and morning-after pills. Barrier methods are also reported as the contraception methods of preference. Another author found that adolescents most use male condoms during their first sexual activity, which is popular because it is easy to access as it is not prescribed [5].
Locations for access to contraception include youth clubs [21], pharmacies [32], shops, peer-distributing condoms, community-level outlets, and NGOs, of which the latter was supported by other authors [1, 16]. However, barriers to contraception access include that PHC facilities are not tailored to meet adolescents' needs [16] because adolescents feel uncomfortable having to use contraception, including not having user-friendliness services that combine adolescents with adults [40, 71, 72]. Adolescents also want more flexible and accommodating service hours as they are in school and cannot attend the PHC clinic in the afternoon. The findings of this study support that there are unfriendly health service providers [1, 16, 73]. Adolescents require contraception counselling and history-taking that avoids missed opportunities for contraception initiation [25]. They also mentioned inflexible and unaccommodating health services, as found by other authors [74], which include working hours. Caregivers complained of rigid working hours, which are not accommodative adolescents, and service providers, which do not offer privacy and confidentiality and do not delay contraception initiation [1].
Adolescents prefer to access contraceptives at pharmacies because pharmacy prescriptions are likely to extend contraceptive access [32]. Youth clubs are also preferred for contraception because some adolescents are not comfortable mixing with adults for sexuality services. Youth state that youth clubs are advantageous to adolescents as they are multipurpose [21]. NGOs were also favourable locations [1] and in Lesotho that would include the Lesotho Planned Parenthood Association.
The use of contraception by adolescents differs in sexually active adolescents. The behavioural patterns of sexually active adolescents that use contraception consistently [75, 76] differ from adolescents with inconsistent use [77] and those not using contraception at all [78, 79]. The advantages of using contraception include the prevention of unwanted pregnancy [1, 76], offer the opportunity to complete school, offer chances for employment, adolescents can contribute to improving literacy rates and economic growth, and preparing adolescent's bodies to be mature enough to withstand pregnancy and delivery [74]. Adolescents must be counselled to make the right informed choices of contraception. The use of contraception also decreases adolescent and infant mortality rates because the adolescent can provide for the infant and prevent malnutrition. Importance of giving adolescents relevant information when sexually active, especially for the first time. Other advantages include employment, avoidance of illegal abortions, and decrease in child abandonment because adolescents are better prepared for parenthood when they are older. Disadvantages of using contraception include the promotion of promiscuity, moreover cultural stigmatization, and immorality [1]. They also believe that contraceptive use amongst adolescents may result in them being infertile in the future when they are married and need children. Literature does not support that use of contraceptives can later cause infertility in the adolescent; instead, when contraception is discontinued, normal fertility status returns [1]. There is also a fear that adolescents are exposed to the risk of careless sexual behaviour resulting in STIs and HIV.
Caregivers report adolescents who are using contraceptives consistently to be more careful in protecting themselves against pregnancy. Consistent contraception use can be motivated by the responsibility to protect self against pregnancy [75, 76]. In contrast, inconsistent use can be due to an unsupportive sexual partner and/or a desire to conceive to qualify for a governmental grant [77].
Caregivers also reported that it is automatic to be judgmental of adolescents who use contraception [80]. Other caregivers consider contraceptive use taboo because contraception usage amongst adolescents is also believed to cause immorality, and the adolescent body will lose tone and become less attractive [1]. However, caregivers did see a need for adolescents to use contraception.
Caregivers reported that they culturally believe adolescents are considered of poor value and have more chances to be stigmatised. From a religious point of view, using contraception interferes with God's will of multiplying [81]. However, besides these beliefs, caregivers realise the need for adolescents to use contraception.
Adolescents need support to prevent adolescent pregnancy, which includes social support, information sharing, and financial for transport for SRH services from the caregivers. Caregivers believe there is a need to advocate for the dilution of cultural beliefs and practices [53] regarding contraception usage amongst adolescents [2]. Other support must emanate from schools whereby they should strengthen the existing life skills curriculum and school health nurses must be deployed at school to assist with health education and contraception [82]. Caregivers felt that school health programmes must be revived as well as conducting outreach services [82-84]. They also mentioned a need to advocate for access to contraception in churches and community gatherings. Health authorities must maximise resources from partners such as Act for Youth in Lesotho, supporting adolescents' access to and use of contraception.
Caregivers believe they must share SRH information with adolescents and recommend that abstinence is 100% effective in preventing unwanted pregnancies and STIs. This can be an integral part of cancelling to improve health literacy for adolescents [16]. Support should be in relation to gender and cultural norms, societal shaming, and religious intolerance [3]. Capitalising on health service providers and revival of school health services for access to contraception are of great importance to school health nurses, where a team of health professionals used to visit schools periodically, and it is no longer happening. Participants responded that health must also consider expanding services such as outreach services and adhering to the schedule. Ideas of outreach services require inclusion for equity purposes hence a need for telehealth and other delivery points [83]. Participants also suggested that health authorities must maximise on engaging, both technical and implementing, to drive adolescents, which includes partners on contraception access and use to prevent HIV and STIs agenda. This concludes that there is a need to partner with communities to succeed in preventing pregnancy by giving support and making contraceptives accessible and usable.
CONCLUSION
Use of contraception by adolescents, whether hormonal or barrier methods, seems to be challenging for most adolescents due to several factors like accessibility and support either at home, schools, or health facilities. Adolescents’ caregivers mostly feel not competent to discuss any topic related to sexuality due to their cultural and religious background, leaving the use of contraception by adolescents as a promotion of promiscuity and future chances to be barren when they are married and expected to have children. If caregivers are empowered, they will contribute more as they are role models for adolescents and will break cultural and religious barriers gradually. On the other hand, schools seem to play a partial role by including basic sexuality education in the school curriculum. At the same time, service providers’ attitudes and rigid health service delivery contribute to adolescents' limited access to contraception. All caregivers recognise the need for adolescents to use contraception but are scared to flag the issue openly. The situation concludes that there is a need to put more effort into adolescents’ access to, use of, and support of contraception to prevent unwanted pregnancies that negatively affect their health and future in Lesotho. Scientific data supports the findings, concluding that they are a valid, true picture of caregivers’ perceptions.
LIST OF ABBREVIATIONS
| COVID-19 | = Coronavirus Pandemic Beginning in 2019 |
| FG | = Focus Group |
| HIV | = Human Immunodeficiency Virus |
| HREC | = Health Research Ethics Committee |
| NGOs | = Non-Governmental Organisations |
| NuMIQ | = Quality in Nursing and Midwifery |
| NWU | = North-West University |
| PAT | = Participant |
| PHC | = Primary Health Care |
| SRH | = Sexual and Reproductive Health |
| STIs | = Sexually Transmitted Infections |
AUTHOR'S CONTRIBUTION
Study design: CMK, TR, KF; Data collection: CMK; Data analysis: CMK, TR, KF; Manuscript writing: CFK, TR, KF; Critical revision of important intellectual content: CFK, TR, KF.
ETHICAL APPROVAL AND CONSENT TO PARTICIPATE
Ethical considerations must be considered in every step, starting from conceptualisation, planning, implementation, report writing and dissemination of findings [30]. The authors obtained approval from Quality in Nursing and Midwifery (NuMIQ) scientific review committee and North-West University Health Research Ethics Committee (HREC) number North West Province (NWU) NWU-00324-21-A1. After approval had been received from these committees, a permission letter with the proposal as an attachment was sent to the Research Ethics Office, Ministry of Health, Lesotho, which in turn issued an approval letter. A copy of the approval and all documents mentioned above were given to the District Health Management Team office at the desk of the District Public Health Nurse to request permission to conduct the research study. Participants signed informed consent forms before participation. Participants' contacts were taken for follow-up one week post the meeting to check if they were not developing COVID-19 signs and symptoms.
HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.
CONSENT FOR PUBLICATION
Informed consent was obtained from all participants.
STANDARD OF REPORTING
CORREQ guideline were followed for this study.
AVAILABILITY OF DATA AND MATERIALS
The authors confirm that all the data supporting the findings of this study are available within the article. There is no additional data available.
FUNDING
None.
CONFLICT OF INTEREST
The authors have declared no conflict of interest.
ACKNOWLEDGEMENTS
The manuscript is based on the master’s dissertation of Mrs. C.K. Khachane. The authors thank the Lesotho Ministry of Health for the permission to collect data and the caregivers of adolescents who agreed to participate in the study.
