Ugandan providers’ views on the acceptability of contraceptive self-injection for adolescents: a qualitative study

Abstract

BackgroundSelf-injection of subcutaneous depot medroxyprogesterone acetate may offer greater discretion and increase access to injectable contraception, particularly for those who face challenges accessing clinic services. In particular, unmarried adolescents often encounter stigma when seeking services, and may also lack the financial means to travel to clinics on the quarterly basis that injectable contraception requires. Whether self-injection is offered to women on a wide scale basis, and to adolescents specifically, will depend in part upon the willingness of providers to train clients of diverse ages and educational backgrounds. This study explores the views of providers with regard to self-injection as an option for women and adolescents in Uganda.MethodsIn-depth qualitative interviews were conducted with family planning providers in Gulu district, to understand their views on injectable self-injection for women, with a specific focus on unmarried adolescents ages 15 to 19 years. The in-depth interviews, which lasted up to 60 min were audio-recorded, translated and transcribed simultaneously, and analyzed using Atlas.ti software to identify key themes and common perspectives.ResultsA total of 40 health care providers were interviewed with equal numbers of each type (public, NGO, and private clinics, pharmacies, and community-based health workers). While most providers were receptive to self-injection for adult women, fewer than half were supportive of adolescent self-injection. Their reservations focused on age, marital status and parity concerns around adolescent use of the injectable more broadly, and concerns about the ability of adolescents to self-inject safely.ConclusionsSelf-injection presents an opportunity to reduce the enormous burden on the public sector health system in Uganda, which is particularly compounded by the heavy reliance on injectable contraception requiring quarterly clinic visits. The results of this study reveal a level of cautious support for self-injection among providers when it comes to self-injection by adult women. With respect to adolescent clients, family planning policymakers and program implementers should design, implement, and evaluate self-injection interventions with the needs of adolescent clients uppermost in mind, recognizing that extra attention will likely be needed to reduce provider-imposed restrictions on adolescent access to this injectable delivery modality.

Contraceptive self-injection through routine service delivery: Health worker perspectives from Uganda

“…We found that a small number of providers expressed reluctance to train adolescent women, highlighting persistent challenges with provider bias against adolescent contraceptive use, and hormonal contraceptive use specifically. These findings are consistent with a previous study in Uganda, which showed reluctance to offer adolescent women contraception (due to adolescent sexuality concerns), injectables (related to infertility impacts) as well as self-injection (perceptions of lack of maturity) ( 22 ). Monitoring to track adolescent access to self-injection (mode of injectable administration by age) is necessary if we are to evaluate scale up in terms of equitable access for young women.…”

Adolescent and Youth Experiences With Contraceptive Self-Injection in Uganda: Results From the Uganda Self-Injection Best Practices Project

“…describe providers' expectations that young women who self-inject will engage in premarital sex or promiscuity, misconceptions that injectables cause infertility, and reservations about offering SI to unmarried adolescents without parental consent (although no policy requiring parental consent exists). A common reason for opposition to adolescent SI: adolescents do not have the maturity to manage it [ 20 ]. However, measuring provider bias is highly challenging [ 21 ], constituting a limitation to our study methodology.…”

Youths’ perceptions of community health workers’ delivery of family planning services: a cross-sectional, mixed-methods study in Nakaseke District, Uganda

“…Approximately 15% of respondents cited a fear of judgment as the reason for discomfort in talking to VHTs; and 7% said that they would fear that a VHT would not treat them well. This fear may be justified, as previous studies in Uganda have found that providers can be disapproving of adolescents engaging in premarital sex and are often reluctant to give adolescents a full range of family planning services [ 60 ].…”