Ever Use of Modern Contraceptive among Adolescents in Uganda: A Cross-Sectional Survey of Sociodemographic Factors ()
1. Introduction
Adolescence, a period when young people develop from childhood to adulthood, presents vast opportunities and increased risky behaviors. It’s time many young people become sexually active and get married with limited or no information and services on how to delay pregnancy. Globally an estimated 20 million pregnancies occur in adolescents every year [1]. There are disproportionately high rates of adolescent pregnancy in developing countries. In low resource settings, 2.5 million births occur in adolescents below the age of 16 years annually [2]. In Africa, 20% of all pregnancies occur in adolescents, with a big burden in the East African Region [3]. Within the developing countries, the burden of adolescent pregnancy is higher among the less privileged poor and the illiterate. Uganda is one of the countries with the highest rates of adolescent pregnancy, estimated at 25% [4]. Adolescent pregnancy has been attributed to various factors including sociocultural, environmental, and economic reasons [5].
Adolescent pregnancy has well-documented consequences for the mother and newborn. There is an increased risk of maternal and perinatal morbidity and mortality during adolescence [6]. Maternal deaths are more common in adolescents and young people with an even higher risk in those below 15 years. Babies born to adolescent mothers are at an increased risk of infant and childhood mortality and morbidity. On the other hand, it is associated with long-term socioeconomic consequences [7] [8]. Adolescent pregnancy is a recipe for poverty in these populations to school dropout and facing rejection from their families [5]. Reducing pregnancy rates in sexually active adolescents can be achieved by the use of modern contraceptives [9].
Low contraceptive prevalence has been reported among adolescents. In 2019, globally 10.2% of sexually active adolescent women 15 - 19 were using modern contraceptives with notably low prevalence and high unmet need in Sub-Saharan Africa [10]. Contraceptive prevalence rates in Uganda among married couples increased from 14% in 2011 to 35%, according to the 2016 Uganda Demographic Health Survey (UDHS 2016) yet that of sexually active married and unmarried adolescents was 25.1%. Uganda’s National policies on contraception use among adolescents allow sexually active adolescents to access contraceptives without the consent of the parent/guardian [11]. To understand what drives contraceptive use in this age group, data on the association between demographic characteristics and the use of modern contraceptives among adolescents is crucial. The objective of this study was to determine the prevalence and factors associated with the ever use of modern contraceptives among adolescents in Uganda.
2. Methods
2.1. Study Design
Crossectional survey of adolescents who self-reported ever having sex. Data were obtained from a community-based survey looking at risk factors for adolescent pregnancy. The participants who self-reported ever having sex (“Have you ever had sexual intercourse?”) were included in the cross-sectional analysis. The main outcome variable was self-reported ever-use of a modern contraceptive (“Have you ever used family planning/contraceptives?”). The Socio-demographic variables included were age in completed years, marital status, education level, employment, socioeconomic status, paternal and maternal education status, parenting styles, knowledge on pregnancy prevention, discussing sex with parents, having a peer who had ever been pregnant, and place of residence (classified as urban or rural). The variables with more than 10% missing data were eliminated from the analysis.
2.2. Setting
The primary study was a community-based survey done in Wakiso and Kamuli districts in Uganda. Wakiso district is situated in the central region of Uganda. It encircles Kampala, the capital city of Uganda, and is predominantly urban. Adolescents aged 10 - 17 years make up 17.3% of the total population in Wakiso [12]. Kamuli district is located in the eastern region of Uganda and is a predominantly rural population with adolescents contributing 28% of the population [12].
2.3. Sampling Procedure
A two-stage cluster sampling approach was employed to select study participants. In the 1st stage of sampling districts were divided into clusters. In the 2nd stage, within each district, a probability proportional to size (PPS) sampling of 20 villages or enumeration areas (clusters) were taken.
In each district, an up-to-date list of villages or enumeration areas with their sizes (number of households in each) was obtained. PPS was done in Stata to obtain 20 clusters/villages for each district. Each cluster was visited and with help LC and VHT and a systematic sample of 10 households was taken. Within each sampled cluster (village), 15 adolescents were selected using systematic random sampling. From the centre of the village, every 5th house was visited by research assistants who took opposite directions. If they did not have an eligible adolescent, the next house was taken until an adolescent was enrolled.
2.4. Participants
The study population involved adolescent girls residing in Wakiso and Kamuli districts. The inclusion criteria were adolescent girls aged 13 - 19 years residing in Wakiso and Kamuli districts. Adolescent girls aged 13 - 17 years who provided assent to participate in the study and whose parents provided written informed consent and girls aged 18 - 19 years who provided informed consent were included in the study. Adolescents, who were mentally handicapped, had severe emotional distress and those who were too ill to participate were excluded.
2.5. Variables
Parental age, occupation and educational level which was classified as “no education,” “primary,” “secondary,” and “tertiary/vocation” education was collected. Self-reported data on parenting style, and history of sexual abuse were collected using an interviewer-administered questionnaire. Data on socioeconomic status were assessed using ownership of household properties and were categorized as: rich, moderate, and poor. Parental marital status was classified as never in a union, married, living with a partner, widowed, divorced, and not living together and whether parents are alive or dead.
2.6. Sexual Reproductive Health Information
Awareness of adolescent sexual and reproductive health information by the adolescents and the sources of Sexual Reproductive Health Information. Knowledge about sexual reproductive health assessed included; Knowledge on prevention of (Sexually Transmitted Infection) STI/HIV, prevention of pregnancy, menstruation, knowledge, and usage of contraception. Data on sexual risk behavior and prevention and personal attitudes towards sexuality and reproduction and peer influences were collected.
2.7. Socioeconomic Status Assessment
A relative wealth index was constructed using principal component analysis from a set of seven questions relating to household assets such as type of material of the floor, type of material for the roof, walls, ownership of household assets, domestic animals, water, and electricity, TV, and Radio. The index was divided into quintiles where the bottom 40% classified as “poor,” the next 40% as “middle,” and the top 20% as “rich” [13].
2.8. Contraceptive Ever Use
Adolescents who reported ever having sex were asked whether they had ever used a modern contraceptive to delay or prevent conception. Modern contraceptive methods include short-acting contraceptives like pills, male and female condoms, diaphragm, emergency contraception, injectable and long-acting reversible contraceptives like Intrauterine devices, implants, and lactation Amenorrhea Method.
2.9. Determinants of Contraceptive Ever Use
Factors were selected to assess factors associated with contraceptive ever use based on Andersen’s behavioral model [14]. It suggests three factors that influence the uptake of health services: 1) predisposing factors, 2) enabling factors 3) required factors such as knowledge of contraception.
2.10. Sample Size
This study was conducted on a subset of participants of a community-based survey on determining risk factors for pregnancy among adolescents 13 - 19 years. In brief, all adolescents that reported to have had at least one sexual encounter were included in this analysis (n = 337). All adolescents had their demographic characteristics, household, sexual reproductive information, and family-related variables measured during data collection.
2.11. Data Tool Development
A structured questionnaire was used for data collection. The questionnaire included a sequence of questions from established tools such as demographic health surveys [4] (women’s questionnaire) and adolescent sexual reproductive surveys [15]. The interviews sought information on socio-demographic and household characteristics, sexual reproductive health knowledge, and behaviors, among others. Data on SRH knowledge was collected using an instrument based on the “Illustrative Questionnaire for Interview-Surveys with Young People”, a core set of instruments endorsed by the World Health Organization [16]. This instrument is widely used in low- and middle-income countries and has been used in several studies where validity has recently been reported to be high (Cronbach’s alpha coefficient of 0.89) [17]. The study tool was pre-tested in Kampala before field data collection. The questionnaire used during data collection is attached as an appendix.
2.12. Data Sources/Measurement
Research assistants were taken through classroom training for two days. Training included adolescent (Sexual Reproductive Health) SRH, protocol training, and data collection techniques. This was followed by pilot testing of all the tools. Participating in pilot training was also a means of training the research assistants.
Data were collected using structured interviews among adolescents through a household-based survey. The interviews were administered on a one-to-one basis and in privacy to individualize the responses and to enhance their validity. This questionnaire captured socio-demographic characteristics of adolescents and their parents, SRH knowledge, behavior, and attitudes.
2.13. Field Data Collection
The field data collection was done from 6th July 2020. Data collection tools were written in English. A team of research assistants was recruited and trained. With the help of the Village Health Team or Local Council 1 Chairman, the interviewers reported to the community leaders and then proceeded to approach the community members. Once in a selected household, the interviewers asked to speak to the selected respondent/adolescent, explained the survey, and obtained written informed consent before the survey proceeded. If the respondent was under 18 years, parental consent was asked before enrolment of the adolescents.
2.14. Data Analysis
The respondent characteristics were described using frequencies and percentages for categorical variables and means, and the standard deviation for continuous variables. The analysis was stratified by the district. The prevalence of contraceptive use among adolescent girls (13 - 19) was by computing the proportion of respondents that reported use of contraception at the time of the survey to the total number of adolescents that have ever had a sexual encounter. To explore the factors associated with modern contraceptive ever use in the rural and urban areas, stratified analysis was performed per the district of residence. We used generalized linear models with a Poisson link to examine factors associated with contraceptive use at both univariate and multivariate regression. The generalized linear models were used because they can estimate prevalence ratios directly compared to the logistic regression models. We assessed for the presence of multicollinearity using variance inflation factors (VIF). One variable was dropped if two or more variables were collinear. The model specification tests were conducted using AIC and BIC to determine the goodness of fit. STATA version 15 (Stata Corporation Ltd. Texas, USA) was used for analysis.
3. Results
3.1. Socio-Demographic Characteristics of Adolescent Girls
The study included 337 adolescents 13 - 19 years of age with a mean age of 17.8 years. The older adolescents 17 - 19 years were the greatest proportion among those who had ever had sex 290/337 (86.0%). More than a third of the adolescents 61/187 (32.6%) in the rural district had never attended school as compared to a quarter: 38 of 150 (25.3%) in the urban district. The majority of adolescents who had ever had sex were from families with poor economic status 149/337 (44.2%). The details of the demographics in the sexually ever exposed adolescents are shown in Table 1.
3.2. Family-Related Characteristics of Study Participants
About half 168 of 337 adolescents had ever discussed sex with a parent, which was proportionately higher in the urban compared to rural settings. Permissive parenting style 145/337(43.0%) was predominant in the adolescents. The adolescents across the regions generally had low knowledge of contraceptives and prevention of pregnancy (3.2) compared to that of prevention of STIs (7.9). Details of other factors related to ever having sex are shown in Table 2.
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Table 1. Socio-demographic characteristics of adolescent girls.
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Table 2. Family characteristics of the study participants.
3.3. Type of Contraceptive Used
The majority of the participants were using injectable contraceptives (30/104) 28.8%, and other short-acting contraceptives like condom use 20.2% (21/104), and (18/104) 17.3% had ever used long-acting reversible contraceptives (IUD and subdermal implants combined). Details of contraception use are shown in Table 3.
3.4. Factors Associated with Contraceptive Use among Adolescents
The older girls aPR 1.31, 95% CI (1.06 - 1.55) **, those who were married aPR 1.67, 95% CI (1.09 - 2.58) ** and educated up to primary level aPR 1.79, 95% CI (1.14 - 2.83) ** were more likely to use modern contraceptives. The adolescent from the urban settings with aPR, 95% CI 0.67, 95% CI (0.49 - 0.92) ** and those from moderate economic status with aPR 0.72, 95% CI (0.51 - 1.02) * were generally less likely to ever use modern contraceptives. Adolescents with peers who
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Table 3. Prevalence of contraceptive ever use among adolescents.
had ever gotten pregnant were generally more likely to ever use modern contraceptives CPR 1.57, 95% CI (1.04 - 2.38) **. Details of the other factors associated with ever use of modern contraceptives after multivariate analysis are shown in Table 4. In the district specific analysis, adolescents with moderate aPR 0.35 95%CI (0.17-0.68) ** or high socioeconomic status aPR 0.62, 95%CI (0.28-1.37) were less likely to use modern contraceptives in the urban setting. The level of significance in all adolescents were significant in the district specific analysis.
4. Discussion
The study aimed to determine the factors associated with the ever use of modern contraceptives among adolescents in Uganda. The data suggests that the older adolescents, those who are knowledgeable about contraceptives, puberty, and those married were more likely to ever use modern contraceptives. In addition, those who had attained primary education and those who had the freedom to the club were more likely to use modern contraceptives. Adolescents from the rural areas who had discussed sex with parents while those in urban settings those from poor households and knowledgeable about contraception and puberty were likely to use modern contraceptives.
The study shows that three in ten adolescents had ever used a modern contraceptive. The majority had used short-acting contraceptives like condoms pills and injectables. The results of this study are comparable to modern contraceptives ever used among adolescents 15 - 19 years in Ghana (35%) [18] and the Demographic Republic of Congo (28.9%) [19]. A lower prevalence (9.5%) of contraceptive ever use among adolescents in Uganda has been reported after a secondary analysis of 2016 UDHS data [20]. This study looked at the utilization of all adolescents irrespective of their previous sexual experience which explains the main differences. The unmet need for contraception among adolescents is much higher than among other women of reproductive age in general [21]. The low prevalence of ever use of modern contraceptives in this population highlights the underlying cause of adolescent pregnancy.
The study found adolescents who were knowledgeable about modern contraceptives were more likely to ever use them. It has been previously found that curriculum-based sex and HIV education programs when given to young people
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Table 4. Univariate and multivariate Poisson regression model.
***P < 0.001, **P < 0.05, *P < 0.1, CPR-Crude prevalence ratios, PR-Prevalence ratio, attending school at the beginning of the year was dropped from the multivariable model because of the missing data (13%).
promote contraceptive use [22]. A study in Uganda found very low knowledge of contraceptives and yet the main source of information was the media [23]. Media is not a reliable means of delivery of SRH information because it may not be accurate or be misrepresented [24]. Knowledge empowers adolescents to make effective choices on the prevention of pregnancy and sexually transmitted infections. Delivery of SRH information to adolescents should be taken as a priority to reduce adolescent pregnancy in Uganda.
The study found that adolescents with primary education were more likely to ever use modern contraceptives compared to those who attained secondary education. This effect was more evident in adolescents from the rural setting. This is contrary to a previous study from Ghana among sexually active unmarried adolescents which showed that attaining secondary education promoted the use of modern contraceptives [18]. Previous studies, in addition, have indicated that older women and those with high education are more likely to use modern contraceptives [25] [26]. The possible explanation in this setting is that high school dropouts in the rural areas due to poverty expose them to more sexual activity and therefore need to use contraceptives. The adolescents who have stayed longer in school are likely to differ sexual activity which explains why the adolescents who had secondary education had less sexual activity and low contraceptive ever use.
Married, older adolescents were more likely to ever use modern contraceptives. Older adolescents are more likely to be exposed to receive information on contraceptives from the health facility as reported previously in a study done in the Democratic Republic of Congo [19]. Married adolescents are likely to be exposed to regular sexual activity as compared to the unmarried and these are also socially acceptable to access modern contraceptives compared to their counterparts.
In this study, adolescents from rural areas were more likely to ever use modern contraceptives. The desire to prevent pregnancy could be influenced by the high rates of teenage pregnancy in rural areas. The finding is contrary to what has been previously shown that adolescents in rural areas are less likely to use contraceptives compared to their urban counterparts [26]. Adolescents in rural areas have been at higher risk of teenage pregnancy [3]. Low socioeconomic status has been independently linked to adolescent pregnancy [27] [28]. It’s likely that as an intervention to prevent pregnancy and consequences of adolescent pregnancy are evident in the rural and poor communities, which motivates them to use contraceptives.
The unlikely findings in this study were that contraceptives are ever used more likely in the urban poor adolescents. Previously it has been shown that the more educated and rich are more likely to use contraceptives [26]. The urban poor adolescents were found to be at a higher risk of adolescent pregnancy compared to the rural poor in Zambia [29]. The urban poor likely has greater temptations to raise economic status at any cost, including risky sexual behavior which predisposes them to pregnancy and therefore, the increased demand for contraception.
Those who had ever discussed sex with their parent and had the freedom to go dancing and clubbing were more likely to ever-used modern contraceptives. Discussing sex with parents has been shown previously to be protective of adolescent pregnancy in Africa [3]. Parental supportiveness is associated with the use of modern contraceptives among secondary students in Scotland [30]. Parents discussing sexual reproductive health issues with the adolescent gives accurate information and empowers them to make good decisions.
5. Limitations
The main limitation of the study was that data on contraceptive ever use got from self-reports which could have brought bias. Data collected on the variables were self-reported which may have affected the data. Details of the contraceptives were captured in the questionnaire; however, data on being out of school at the beginning of the year had missing data and was not included in the analysis. Data was collected after the COVID 19 lock-down of schools in Uganda which may have affected the sexual exposure of the adolescents and possibly the use of contraception. In addition, the cross-sectional nature of the study data does not give a causal interpretation of the findings. However, the sample size was adequate and the data collection tools were validated. The data was collected from two districts in Uganda and is not representative of all adolescents in Uganda.
6. Interpretation
This study presents the results of an analysis of recent data on contraceptive ever use among adolescents in Uganda. This analysis allowed us to assess factors associated with contraceptive ever use among adolescents. Stratified analysis was conducted to determine whether the associated factors were affected by the residence of the adolescents, which revealed that older and married adolescents were more likely to ever use modern contraceptives. In the rural district, those who had discussed sex with their parents were more likely to use contraceptives. Vulnerable adolescents like the poor and less educated were more likely to use modern contraceptives. Empowering the girl child early with knowledge, especially with the parent as the primary source may be a good strategy for promoting contraceptive use among adolescents. The different stakeholders, including parents, health workers, and policymakers should consider using this evidence to guide decisions on the provision of SRH information regarding contraceptives in adolescents and preadolescents.
7. Generalizability
The results of the study are not generalizable to all adolescents in Uganda. It’s representative of adolescents in the selected rural and urban settings.
Acknowledgements
We would like to acknowledge all the adolescents and their parents/guardians who took part in this study. The research assistants who participated in the data collection. The district health and Village health teams at Kamuli and Wakiso districts introduced us to the community.
Ethics Approval and Consent to Participate
The study was approved by the Makerere University School of Public Health Research and Ethics Committee (HDREC 768) and the Uganda National Council of Science and Technology (SS 5236). All study participants provided informed consent and assent before participating in the study.
Availability of Data and Materials
All data generated or analyzed during this study are included in this published article.
Authors’ Contributions
All the authors contributed to the conception and conduction of the study. FN drafted the first manuscript and all authors contributed and approved the final draft.
List of Abbreviations
SRH: Sexual Reproductive Health
STI: Sexually transmitted infections
VHT: Village Health teams
aPR: Adjusted Prevalence Ratio
CPR: Crude Prevalence Ratio
Annex 1: Quantitative Study Instrument
Survey Questionnaire
Sexual and Reproductive Health Information
Makerere University
Section 1: Identification Particulars
001 QUESTIONNAIRE ID No. |___|___|___|___|___|___|
002 INTERVIEWER NAME: _____________________________
003 DISTRICT: _______________________
004 NAME OF VILLAGE: ________________________
005 NAME OF SUB COUNTY:_____________________
006 Rural = 1 Urban = 2 Other (specify) _________
007 DATE OF INTERVIEW: ___/____ / 2020
ASK: Please confirm that you are between 13 and 19 years
IF THE RESPONDENT DOES NOT FIT THE CRITERIA…Tell them you cannot interview them,thank them, and end the interview.
008 Interview Result: Result codes: Completed = 1; Partially Completed = 2; Refused = 3; Other = 4
009 DECIDE CATEGORY
Ever been or currently pregnant: 1
Never been pregnant: 2
010 INTERVIEW CHECKED BY SUPERVISOR:
SUPERVISOR SIGNATURE ______________CODE |___|___| Date ___/____ / 2020
Section 2: Background Characteristics
First, I have some questions about yourself
Section 3: Family Environment
Now, am going to ask you questions about your family and yourself?
Section 4: Status of the Household Wealth
INSTRUCTION: Now am going to ask you questions about social economics status of the household
Section 5: Sexual Reproduction Health Information
Section 6: Accuracy of Sexual Reproductive Information
THANK YOU VERY MUCH FOR YOUR COOPERATION