FACTORS IMPACTING ON CONTRACEPTIVE USE AMONG YOUTH IN NORTHERN TSHWANE: PART 2

Young people are vulnerable to risky behaviors that cause major health problems such as sexual behaviour resulting in early, unplanned pregnancy and sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV).This study intends to identify and describe factors impacting on the utilisation of contraceptives and contraceptive services among youth in Northern Tshwane. A purposive sampling method was used to select participants who met the set criteria. Two focus group interviews were held with youth who visited the selected health care centres for contraceptives and those who had terminated a pregnancy. The interviews were tape recorded, field notes were made during interviews and these were transcribed verbatim. The findings revealed that a number of factors play a major role in non-utilisation of contraceptives and contraceptive services.


INTRODUCTION AND BACKGROUND
Youth constitute a significant percentage of populations worldwide including the Republic of South Africa (RSA).
Estimates are that youth constitute 60-80% of populations in developing countries (Heunis, Engelbrecht & Ngwena, 2000:54;Mohammad, Farahani, Alikhani, Terhani, Ramezankhani & Alaedini, 2006:35).Young people are a great potential for the future with new ideas and hopes and thus promoting their reproductive health should be a priority from homes, schools, policy makers and health planners.Youth become sexually active at an early age with resultant early, unintended pregnancies, mainly occurring outside marriage.Inadequate and inconsistent use of contraceptives by sexually active youth who engage in sex often results in early and unplanned pregnancies which either result in early parenthood or with termination of pregnancies.The World Health Organization (WHO, 1998:6) estimates that close to 17 million girls under the age of 20 years give birth annually and a further 4.4 million abortions are sought by adolescents each year worldwide as a result of inadequate and non-utilisation of contraceptives.In the RSA, Mwaba (2000:30) reported that the annual number of babies born to adolescents younger than 16 years is approximately 17 000 adding to the Department of Health's (DOH, 1999:5) report which revealed that the 1998 South African and Health Survey, showed that 35% of adolescents were pregnant before the age of 20 years.These unintended pregnancies could be averted by effective and consistent use of contraceptives as reported in the United States of America where an estimated 1.65 million pregnancies among youth aged 15 to 19 years during 1995 were averted.If these women had been denied access to contraceptives, an estimated additional one million pregnancies would have occurred (Kahn, Brindis & Glei, 1999:29).Young girls are at higher risk of dying from pregnancy and delivery complications.According to the WHO (1999:13), girls aged 15 to 19 years are twice as likely to die during pregnancy or delivery as compared to women aged 20 to 34 years.
Both early parenthood and termination of pregnancy (TOP) have detrimental effects on youth and their immediate families.Research indicates that adolescent or teen pregnancy results in health, social and eco-nomic implications for mothers and their offspring including their families or extended families (Ehlers, Maja, Sellers & Gololo, 2000:53;Modungwa, Poggenpoel & Gmeiner, 2000:62;Williams & Mavundla, 1999:59).
Young mothers experience higher morbidity and mortality during pregnancy and labour than adult women.
The increased health problems include anaemia, STDs and AIDS, prolonged labour due to cephalo-pelvic disproportion and hypertensive disorders during pregnancy and labour.
When faced with unwanted pregnancies, many young girls choose TOP as their recourse.TOP is done either through the legal or illegal system.In most developed countries, TOP is a legal procedure whereas in developing countries and only a few African countries, TOP is permitted for reasons other than those threatening life.Global estimates indicate that 19 million unsafe TOPs are performed and 18.4 million of these, occur in developing countries.Complications from unsafe TOPs account for 13% of the total maternal deaths worldwide.More than 60% of all unsafe TOPs in developing countries occur among women aged 15 to 30 years (Ahman & Shah, 2004:6;WHO, 1998:8).Research conducted at four public hospitals in Dar es Salaam showed that about a third of women admitted with complications from illegal TOPs were teenagers, 41.3% of whom were 17 years or younger (Mpangile, Leshabari & Kihwele, 1993:21).The liberalisation of TOP laws has been a major factor in the reduction of maternal mortality rates, and has had a decisive influence on women and young girls' general health conditions.
In the RSA, the Termination of Pregnancy Act (No 92 of 1996) became operative in February 1997.This Act enables women from the age of 12 years to decide to terminate their pregnancies before 12 weeks gestation without permission of their parents and partners.Since the implementation of the Act, the total number of legalised TOPs performed in the RSA were 177 462 by mid 2000.National statistics indicate that in the RSA, 17.4% of women requesting for TOP are below 18 years (Barometer, 2000).Although still a controversial procedure, TOP should be used as a last resort in preventing unwanted pregnancies, mainly among youth.

PROBLEM STATEMENT
Youth are often challenged by external and internal pres-sures to use contraceptives and contraceptive services ineffectively with resultant socio-economic pathologies such as sexually transmitted diseases, HIV/AIDS, early unplanned pregnancy, repeated termination of pregnancies and their complications.Unless these pressures or factors can be identified and addressed, the pathological consequences will continue to plague youth, families and communities.This article intends to identify factors impacting on effective utilisation of contraceptives and contraceptive services among youth.
The following questions were posed to participants to guide the study: • Which factors impact on your effective use of contraceptives and contraceptive services?• What recommendations would you make to improve contraceptive use among youth?

PURPOSE OF THE STUDY
The purpose of this research was to explore and describe the factors impacting on the use of contraceptives and contraceptive services among youth in Northern Tshwane.

OBJECTIVES OF THE STUDY
Objectives of this research aimed to: • Identify and describe factors impacting on contraceptive use and utilisation of contraceptive services among youth.• Suggest recommendations to improve contraceptive use among youth.

RESEARCH METHOD
An exploratory, descriptive, and qualitative design (Holloway & Wheeler, 1996:2-3) was used to explore and get detailed information about the factors impacting on contraceptive use as well as utilisation of contraceptive services among youth in Tshwane, Gauteng Province.

POPULATION AND SAMPLING
The population of this study comprised youth who either came for contraceptive consultation and girls who had terminated a pregnancy within two to six hours at health care centres selected for the study in Northern Tshwane.These two health care centres were selected because they were geographically accessible to the researcher and that they were next to schools where adolescents sought contraceptive services on a daily basis.

Sample
Purposive sampling (Polit & Hungler, 1999:235) was used to select youth who met the set criteria.Purposive sampling is judgemental sampling that involves the conscious selection of certain subjects or elements by the researcher to include in the study (Burns & Grove, 2001:475).The researcher selected consciously a total of 26 young girls and boys to participate in two focus group discussions.One group comprised twelve girls who had terminated a pregnancy at the health care centre, whilst the other had six males and eight females, making a total of fourteen who visited the health care centre for contraceptives.The sampling criteria were: • youth aged 16 to 20 years; • females and males visiting the health care centres in Northern Tshwane for contraceptive services; • girls who had terminated a pregnancy at the health care centre within two to six hours; and • voluntary participation.

DATA COLLECTION
Focus groups were the method of choice to gather data.
A focus group interview is defined as a qualitative technique, using discussion among a group of 4-12 people in a comfortable, non-threatening environment, to explore topics or obtain perceptions about a given problem or topic of interest.
Two separate focus groups (one group males and females, the other, females who had TOP) were held with participants at the health care centres.A room without distractions was used and a facilitator, with interviewing skills conducted the focus group interviews whilst the researcher tape recorded and took field notes which, were later transcribed verbatim (Burns & Grove, 2001:305).During the discussions, participants were led to explain their experiences in narrative style using interviewing techniques such as observation, maintaining eye contact, nodding, paraphrasing, reflecting and summarising.Each focus group discussion lasted 45 to 60 minutes.

ETHICAL CONSIDERATIONS
Participants who met the sampling criteria were asked to participate voluntarily and verbal consent was obtained.Information about the research was read to participants and they were assured of anonymity and confidentiality.The researcher reassured the participants that no link would be made to individuals when describing the findings.Participants were informed of their right to withdraw from the study at any time without any fear of victimisation.Permission to conduct the study was obtained from authorities of the two health care centres selected for the study.Participating health care centres would also not be identified or linked to the specific interviews as the research report would only address the general findings for all participants from all health care centres combined.

STRATEGIES TO INCREASE TRUSTWOR-THINESS OF THE FOCUS GROUP DATA COLLECTION METHODOLOGY
Strategies for ensuring trustworthiness were followed according to Guba's (in Krefting, 1991:214-222) model of trustworthiness.The main aspects of the model include credibility, transferability, dependability and confirmability.

Credibility strategies
• Activities in achieving credibility were prolonged engagement in the field.An extended time was spent with participants.This allowed the participants to become more accustomed to the researcher.
• Reflexivity was another strategy used and it refers to the assessment of the researcher's own background, perceptions and interest on the qualitative process.After each group met, the researcher reflected on the data collection.
• Triangulation is based on ideas of convergence of multiple perceptions, for mutual confirmation of data, to ensure that all aspects of a phenomenon have been investigated (Krefting, 1991:219).Different data collection methods were used such as tape recordings and field notes for the purpose of audi-bility (Krefting, 1991:218).
• Peer examination was also used.The researcher discussed the research process and findings with expert colleagues who have experience with qualitative research and reproductive health.
• Member checking was ensured by providing feedback to the participants regarding the themes that emerged in order to obtain their reactions and to explore if these interpretations were a good representation of the participants' reality.

Transferability
• Transferability was achieved by a dense description of the data collection method and data analysis.
• The context of the research was also described thoroughly.
• Participation was voluntary.
• A literature control was done after data gathering and data analysis had taken place.

Dependability
• Interviews were conducted until data became apparent.
• The researcher transcribed tape recorded data.
• The independent coder independently analysed the data and a consensus discussion was held to confirm the results.

Confirmability
• Confirmability strategies used included an audit trail of the research process, reflexive journal and triangulation of data sources (Krefting, 1991:222).

DATA ANALYSIS
Tape recorded data were transcribed by the researcher and an independent coder separately from each other using Tesch's model (in Creswell, 1994:154-155) of data analysis.The steps of the model followed were: • The researcher got a sense of the whole, by reading through all the transcripts.Some ideas were jotted down.
• One interview was chosen to start the analysis.
Thoughts were written down as they occurred.
• The researcher completed this with several of the participants' transcribed interviews.A list of all found topics was compiled.Similar topics were clustered together and formed into columns.The columns were arranged according to major topics.• These topics were then abbreviated as codes and descriptive wording given to each topic which were turned into themes.
• The researcher found the most appropriate descriptive wording for the topic and turned these into categories.Grouping topics that relate to each other reduced the total number of categories.
• The researcher made a final decision on the abbreviation for each category and assembled them alphabeticaly.
• The data material that belonged to each category were then assembled and a preliminary analysis was performed.
• Consensus discussions were held by the researcher and an independent coder regarding the findings.
A literature control was conducted to identify the similarities and differences between the study and previous research (Creswell, 1994:24).

RESULTS AND DISCUSSION
Five major themes were identified from the factors impacting on contraceptive practices: • Inadequate information about some methods of contraception.
• Poor communication regarding sexuality issues among youth and their parents.
• Inaccessibility of contraceptive services.
• Services unfriendly to youth.

Inadequate information about some methods of contraception
From the discussions held with the mixed group of youth, it emerged that most males were not adequately informed about different contraceptive methods and services that could be used for contraception as compared to young girls who seemed to have some information about contraception.One male participant indicated: "I've heard that there are methods which can be used to prevent pregnancy, but do not have correct, detailed information about these contraceptives.I only know about condoms which are used by males.When we go to clinics to get condoms the nurses just point at the condom machine without discussing anything with us.We need more information even about these condoms because many guys pretend to be knowing how to use them even if they don't ...".Young people have been reported to have inadequate knowledge about the reproductive function and consequently lack knowledge about contraception.In their study on "Socio-cultural deterrents to family planning practices among Swazi women" Ziyani, Ehlers and King (2003:46) reported that 60% of participants were not informed about contraceptives, no information was available in their communities and that education programmes were unavailable to their schools.Ehlers, Maja, Sellers and Gololo (2000:48) and Seekoe (2005:20) propose that information regarding sexuality issues including contraceptive practices should be imparted early in the socialisation process of both girls and boys at homes, schools and community places.

Another
Having such information during early stages of life could assist in equiping individuals with better skills to protect themselves against unintended pregnancies.

Poor communication among parents and their children about sexuality issues
Lack of communication among youth and their parents about sexuality issues including contraception was reported by youth as a major stumbling block which resulted in unplanned adolescent pregnancies.One participant stated: "It's not always easy to discuss sexuality issues and contraception with your parents … my mother is more approachable than my father … but I don't just have the guts to start these topics with my parents as they always think that we are children who do not have sexual needs … and must be obedient as long as you are dependent on them".
From the mixed group another expressed: "When these young girls and boys appear on TV, maybe in soapies as lovers, then the comments you'd hear from my parents are actually directed at me and my sister … such as … these soapies are teaching our children wrong things … and at times you'll just be told about homework to get you away from watching TV or change the channel without even considering you".
Adolescents' access to education and information on sexual matters, including contraception has been seriously neglected, for fear of promiscuity or infertility.
Cultural barriers and respect for elders in discussing sexuality issues compounded the problem as neither parents nor youth could initiate the conversation (Seekoe, 2005:27;Mohammad et al. 2006:35).Wood and Jewkes (2000:5) noted that most mothers would not discuss menstruation or had simply informed their children that it was a process of growing up without giving full details about what to expect and how to prevent pregnancies.

Inaccessibility of contraceptive care services
The concept of accessibility is identified by the Department of Health (1992:2) as the continued organised supply of an equitable level of health care that is easily reachable to all citizens, be it in geographical, functional or cultural terms.Although health care services, mainly clinics are within reasonable reach in communities, they are often not used effectively by youth due to various barriers as evidenced in the following statement: "We have services at our neighbouring clinic, but it is not easy to get supplies of condoms at this clinic, especially if you are still young like 'me'….I mean I am 19 years, sexually active and have a steady girlfriend.I want to use condoms regularly to protect ourselves against HIV/AIDS and pregnancy.Every time you go to the clinic, you are told that there's no stock … I can't afford buying condoms from the pharmacy nor afford travelling to other clinics as they are too far".
Failure of services to provide clients with methods of choice or continual contraception because of lack of stock, may hamper the effective utilisation of such health services by clients.The WHO (1996:26) urges that adequate and appropriate equipment and supplies must be maintained and held in stock so that contraceptives can be offered when needed.Failure of services to provide clients with methods of choice or continual contraception because of lack of stock, may hamper the effective utilisation of such health services by clients.

Gender Issues
Male domination was perceived as an obstacle to contraceptive use in instances where young girls had to take their own responsibility in protecting themselves against unintended pregnancies without the help of partners.Young girls who came for TOP felt betrayed by their boyfriends who were not supportive in preventing pregnancies as expressed: "All along we were in good terms with my boyfriend … the problem came when I told him that I was pregnant.He became very angry with me when I explained that I did not have any pills the night I fell pregnant and could not tell him to use a condom because he would not listen to me.After eight weeks of pregnancy, he insisted that I should terminate my pregnancy.When I told him that the foetus was grown up already he disappeared … that's why I decided to terminate because I will have nobody to help me with the baby".
Women are often disempowered and have little bargaining power to negotiate the use of male condoms particularly if they depended financially on their partners.Young girls have become even more vulnerable (Maforah, Jewkes & Wood, 1997:80;Maja & Ehlers, 2004:43;Tabi & Frimpong, 2003:244).In addressing this concern, Karim (1995:154) proposes that women should be equipped with negotiating skills to enable them to discuss sexual and other issues with their partners.

Services unfriendly to youth
Health care providers may contribute positively or negatively to patients/clients' utilisation of heath care services.Patients/clients regard the overall quality of care, including the manner in which they are treated as being the most important aspect of contraceptive service.
One participant stated: "I knew that I could obtain con-traceptives from the clinic to prevent unplanned pregnancy as I was still at school.I was very scared to go to our neighbouring clinic because the atmosphere there is not good … I am 17 years and went to this clinic twice to ask for contraceptives.I could not get the injection I requested for, instead the nurse said I know too much because I even prescribe for myself.I pleaded that I did not want my parents to know that I have a boyfriend and was using contraceptives … that is why I preferred an injection as nobody would know except the nurse … but my efforts failed and I am forced to take the pill against my will ".
Youth have also reported feeling uncomfortable to express their feelings and health care needs in the presence of elder persons.Their most important concerns when seeking contraception from state clinics were the attitudes of nursing staff towards them.Wood et al. (1998:26) reported in their study conducted from the Northern Province, that adolescents were harassed by nurses who were rude, short tempered and arrogant.In the same study, nurses acknowledged that the effects of their comments were usually to make a teenager shy and embarrassed.The duty of confidentiality to a sixteen year old is exactly the same as it is to an adult.Yet Donovan, Mellanby and Jacobson (1997:716), noted in their study on "Teenager's views on the general practice consultation and provision of contraception", that 25 -50% of teenagers were worried that a request for contraception would be disclosed to their parents.

LIMITATIONS OF THE STUDY
The two health care centres used for the study are both located in Northern Tshwane of Gauteng Province.These findings cannot be generalised to other areas as other provinces were not included in the sample.
Young girls who participated in the focus group after termination of pregnancy seemed to have been uncomfortable with having to explain the factors that impacted on their contraceptive use and contraceptive services.
However after being reassured by the researcher, they contributed in the discussions.

CONCLUSIONS
It has become apparent from this study that youth still experience barriers in obtaining and utilising contraceptives effectively.One of the greatest needs of youth, particularly males, was information as they reported not receiving it at school or home.Their communication with parents regarding sexuality issues was limited, owing to cultural barriers, respect and fear of elders.
Furthermore, young girls could not exercise their sexual rights as some could not suggest the use of condoms when having sex with boyfriends with resultant unwanted pregnancies and TOP.
Inaccessibility of contraceptive services was reported in terms of inadequate resources where neighbouring services did not have condoms for clients, particularly youth.This resulted in youth engaging in unprotected sex as they could not afford to travel to further health care services.Health care professional were reportedly negative towards youth requesting specific contraceptives with the result that clients had to settle for any contraceptive method offered.

RECOMMENDATIONS
The following recommendations were made based on the findings of this research: • Empowering youth, particularly girls to make better, informed decisions.Men should also be fully informed about different contraceptive methods used by women so as to support them when contraception is needed.
participant who had terminated a pregnancy stated: "We do have some information about certain contraceptives although not all of them … if I knew about these contraceptives which one can use after an accidental pregnancy, I would have used it … It's a pity I just heard about this when we were in the waiting room ready for TOP.It's not a pleasant procedure to undergo … I had an accidental pregnancy because I did not have any pills left and my boyfriend didn't have condoms either …".
Health care providers should listen to each client's needs, establish open, interactive communication and maintain professional confidentiality to ensure a trust relationship with clients.

•
Sexuality education should become part of the norms taught in families by parents and elders, particularly as youth become sexually active at an early age and in view of escalating HIV/ AIDS and adolescent pregnancies.Schools, churches and youth organisations could play additional roles in promoting reproductive health and educating youth about sexuality issues.Youth should be more open with parents and share information regarding sexuality issues.• Health care providers providing services to youth should be motivated, youth friendly and nonjudgemental.They should be more constructive in their professional relationships with youth, and regard them as autonomous individuals who should prevent unintended pregnancy.Youth should be more respectful to nursing staff and appreciate the service they get.• Innovative, flexible working times at health care services should be considered in tailoring services to meet young peoples' needs.• Health care providers providing contraceptives should always ensure that they have enough stock at all times for continuous provision of service.