Factors influencing the uptake of contraception services by Vatsonga adolescents in rural communities of Vhembe District in Limpopo Province , South Africa

Adolescence is a period characterised by increased exploration and exposure to risk-taking behaviours, including unsafe sex (Gomes et al. 2006:214). Unprotected sexual intercourse can lead to an unwanted adolescent pregnancy, which is often considered a serious social and public health problem (Gomes et al. 2006:215; Mestad et al. 2011:493). Contraceptive usage by adolescents has been perceived to be influenced by various factors, including, socio-economic status, knowledge about contraceptives, attitudes about issues related to contraceptives, residential area, educational status, counselling received about contraceptives, attitudes of the contraceptive providers, cultural values, beliefs and norms according to the Department of Health (DoH) (DoH 2001:11; Kanku & Mash 2010:564). In the study by Davies et al. (2006:44) it was indicated that contraceptive use has increased amongst adolescents in recent years. However, Manlove et al. (2000:167) report that consistent reliance on effective forms of contraception remains low. Reasons for inconsistent contraceptive use are diverse and complex, hence they cannot be easily characterised. (Davies et al. 2006:44). Understanding adolescent pregnancy involves recognising the complexities surrounding adolescent attitudes and knowledge towards using contraceptives (Ehlers & Khoza 2001:8). Richter and Mlambo (2005:66) and Kibret (2003) state that teenage pregnancy appears to be encouraged by a lack of access to sex education. A study by Kaufman, De Wet and Standler (2001:154) found that teenage mothers appear to be ignorant about issues such as puberty, pregnancy, labour, child care and contraception. Ignorance, aggravated by cultural taboos about discussing sex with one’s parents, combined with real or perceived peer group pressure to engage in sexual activities, and cause unnecessary heartache for many young women (Arai 2003; Bankole et al. 2007:200). The aim of the study was to determine the factors that influence the uptake of contraception services by adolescents in the Vhembe district of Limpopo Province, South Africa. A qualitative research method which is explorative, descriptive and contextual in nature was used to investigate the phenomenon from the adolescents’ perspective. The target population comprised of adolescents residing in one of the six villages of Vhembe District. Data was collected through six focus group discussions until data saturation was achieved. Data was analysed using an open coding method. The findings revealed that adolescents are aware of the availability of contraceptive services. However, they lack a comprehensive knowledge about contraception and contraceptives, which led to negative attitudes towards using the services. Cultural health beliefs and attitudes were also identified as a barrier to the uptake and use of contraceptives. Recommendations were made on interventions to increase the uptake of contraception services amongst adolescents.


Introduction and background
Adolescence is a period characterised by increased exploration and exposure to risk-taking behaviours, including unsafe sex (Gomes et al. 2006:214).Unprotected sexual intercourse can lead to an unwanted adolescent pregnancy, which is often considered a serious social and public health problem (Gomes et al. 2006:215;Mestad et al. 2011:493).Contraceptive usage by adolescents has been perceived to be influenced by various factors, including, socio-economic status, knowledge about contraceptives, attitudes about issues related to contraceptives, residential area, educational status, counselling received about contraceptives, attitudes of the contraceptive providers, cultural values, beliefs and norms according to the Department of Health (DoH) (DoH 2001:11;Kanku & Mash 2010:564).In the study by Davies et al. (2006:44) it was indicated that contraceptive use has increased amongst adolescents in recent years.However, Manlove et al. (2000:167) report that consistent reliance on effective forms of contraception remains low.Reasons for inconsistent contraceptive use are diverse and complex, hence they cannot be easily characterised.(Davies et al. 2006:44).Understanding adolescent pregnancy involves recognising the complexities surrounding adolescent attitudes and knowledge towards using contraceptives (Ehlers & Khoza 2001:8).Richter and Mlambo (2005:66) and Kibret (2003) state that teenage pregnancy appears to be encouraged by a lack of access to sex education.A study by Kaufman, De Wet and Standler (2001:154) found that teenage mothers appear to be ignorant about issues such as puberty, pregnancy, labour, child care and contraception.Ignorance, aggravated by cultural taboos about discussing sex with one's parents, combined with real or perceived peer group pressure to engage in sexual activities, and cause unnecessary heartache for many young women (Arai 2003;Bankole et al. 2007:200).
The aim of the study was to determine the factors that influence the uptake of contraception services by adolescents in the Vhembe district of Limpopo Province, South Africa.A qualitative research method which is explorative, descriptive and contextual in nature was used to investigate the phenomenon from the adolescents' perspective.The target population comprised of adolescents residing in one of the six villages of Vhembe District.Data was collected through six focus group discussions until data saturation was achieved.Data was analysed using an open coding method.The findings revealed that adolescents are aware of the availability of contraceptive services.However, they lack a comprehensive knowledge about contraception and contraceptives, which led to negative attitudes towards using the services.Cultural health beliefs and attitudes were also identified as a barrier to the uptake and use of contraceptives.Recommendations were made on interventions to increase the uptake of contraception services amongst adolescents.

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The study by Kaufman, De Wet and Stadler (2001:158) indicates that there was a slightly lower level of knowledge about modern methods of contraception amongst sexually inexperienced women.The authors further report that young mothers in Soweto, Gauteng, were not knowledgeable about sexuality and lack information on contraception and contraceptive use.Other studies reported that adolescents have inaccurate knowledge on the use of contraceptives (Abiodum & Balogun 2008:147;Bankole et al. 2007:199).Wood and Jewkes (1997:43) indicate that in Limpopo Province girls use contraceptive pills when partners visited them, and stop taking the pills when they experience side effects.Ehlers and Khoza (2001:3) investigated adolescents' knowledge and attitude towards contraception and uptake of contraceptive and identified lower levels of knowledge and negative attitudes towards contraception.

Problem statement
The researchers for this study are lecturers who accompany nursing students to clinical training and community visits.During these visits researchers became aware of the high number of adolescents coming for antenatal care at the clinics.As indicated in the DoH (2001) report, Government hospitals of Limpopo Province recorded a total of 7754 live births from teenage mothers during the 2001 calendar year.A total of 572 births were recorded in one particular hospital in the Vhembe District.At a particular clinic, statistics showed that of the 450 pregnant mothers that came for antenatal care between January and March 2010, 30% of them were women aged 15 to 19 years.Registered nurses further indicated that adolescents would prefer termination of pregnancy (TOP) as a method of contraception instead of other preventative measures.It was therefore necessary to explore the factors that influence the uptake of contraceptive or family planning services by adolescents in the rural areas of Vhembe district in Limpopo Province.

Research question
What are the factors that influence the uptake of contraception or family planning services by adolescents in the rural areas of Vhembe district?

Aim of the study
The aim of this study is to explore and describe the factors that influence the uptake of contraception or family planning services by adolescents in the rural areas of Vhembe District.

Research objectives
The objectives of this study were to: • Identify factors which influence the uptake of contraception by adolescents in the rural areas of Vhembe District.• Recommend strategies that could improve the uptake of contraceptives by adolescents in the rural areas of Vhembe District.

Definition of key concepts
The concepts that are central to this study are defined as follows: Uptake of contraceptives: In this study uptake of contraception means the use of contraception by adolescents in the rural areas of Vhembe District of Limpopo Province.
Adolescents: In this study adolescent means any personboy or girl -between 10 and 19 years of age and residing in the rural areas of Vhembe District.
Contraception: A form of birth control which prevents the sperm from fertilising the egg is a contraceptive agent.Contraception includes barrier methods, such as condoms or diaphragm, injectable contraceptives, and hormonal contraception, also known as oral contraception (Maja & Ehlers 2004:44).

Rural communities:
In this study rural community means communities residing in the areas under the traditional authorities (chiefs).

Significance of the study
Collecting data about the uptake of contraceptives by youth is of importance in the prevention of teenage pregnancy, termination of pregnancy and transmission of sexually transmitted infections.The research would reveal the factors faced by adolescents trying to access contraception, and strategies to address challenges could then be developed.

Research Design
A qualitative, explorative, descriptive and contextual research approach was used (Polit, Beck & Hungler 2001:383).The study was inductive as the main focus was to understand the phenomenon from the perspective of the adolescents.
Participants were studied in their own setting in the villages, using one family per village for focus group purposes.An explorative approach was used: the researcher used one question as a point of departure and more questions emanated from the discussions (Halloway & Wheeler 1996:17).

Context of the study
Context describes the uniqueness of the research settings.In qualitative research, the meaning of social action depends on the context in which the study is taking place (Neuman 1997:33)

Study sample
The target population for this study was all adolescents in the Vhembe District of Limpopo Province.Villages with high statistics of teenage pregnancies and sexually-transmitted infections (STIs) were sampled.The number of villages used for the study was six.A purposive sample was used to select the adolescents.These adolescents were identified by a contact person who was a teacher in the school within each village and who, with the assistance of a student leader in the schools, identified the participants that formed the focus groups.The ages of the adolescents in the study ranged from 13 to 19 years.Only adolescents involved in an intimate relationship with a person of the opposite or same gender, who has a child or children, or were pregnant, were interviewed.The sample consisted of 23 boys and 34 girls.Six focus groups were conducted with the participants as indicated in Table 1.

Data collection methods
Data was collected through focus groups using unstructured interviews.More questions emanated from the discussion.Focus group discussions were conducted in one participant's home in each village.The group leaders identified by the teacher in the villages identified both the participants and the venues for the focus groups.The researcher then visited the owners of the venues to confirm the dates and make further arrangements.The homes provided the natural setting for discovery of the social world of cultures and languages by observing and talking to them (Halloway & Wheeler 1996:17).Permission to participate in the study was sought from parents and informed consent was signed.
The criteria for inclusion in the study were not disclosed to parents.Data was audio recorded, whilst field notes and observational notes were taken.The central question that directed the interviews was: 'In your opinion, what could be factors that influence the use of family planning and/ or contraception by adolescents in this area?'This question was translated into Xitsonga ('Hi ku vona ka wena i ncini lexi xi hlohletelaka vantshwa ku tirhisa kunguhat') to make it easier for the participants to understand and participate.Paraphrasing and probing follow-up questions were included to deepen the discussions.A sample size of 57 was reached after data saturation was reached (see Table 1).

Data analysis
Data analysis was done concurrently with data collection (Creswell 2009:192).Data was transcribed and then translated verbatim from Xitsonga to English by a language practitioner.
Recorded information was also compared with transcribed data to avoid omissions.Analysis was done guided by eight steps of Tesch's open coding method (Creswell 2009:193).
Literature control was also undertaken.

Ethical considerations
Permission to conduct the study was obtained from the following institutions: the Department of Education and Culture of Limpopo Province to access the teachers and student leaders who helped in the identification of participants, and the chiefs of the villages where data was collected.Ethical clearance was obtained from the University of Venda.Permission was also obtained from parents through an informed consent or assent form, depending on the ages of participants.The consent form was translated into Xitsonga to assist participants in gaining more information and to make it easy for them to understand.Participants were made aware of the use of an audiotape and were informed about voluntary participation.Participants' names were not used; instead code names were used during interviews (Burns & Grove 2003:172).

Trustworthiness
Principles outlined by Guba and Lincoln (1985:295-331) were followed for ensuring and assessing trustworthiness.Credibility was achieved through spending time with all participants during consent form acquisition and focus group interviews.Tape recordings made and field notes taken during focus group interviews increased the confirmability of the research.Transferability was ensured by complete description of the research method, and interpretation of the research findings in the study report.In-depth literature control on the topic of the study and verbatim quotes cited in the findings enabled the researchers to do self evaluation of their own experiences of the relevant phenomenon.This ensured that the researchers' viewpoints are not reflected.

Results and discussions
Fifty-seven participants participated in this study.Of this number, 23 were boys and 34 girls.Six focus groups discussions were conducted and each focus group lasted for about 1 hour and 20 minutes.Their ages ranged from 10 to 19 years.All participants were Xitsonga-speaking people as this was the main cultural group in the villages selected.One theme together with sub-themes emerged from the analysed data.

Theme 1: Factors related to access to information about the use of family planning
Adolescents expressed factors that they view as barriers in accessing contraception services in health care settings.In expressing these challenges the following sub-themes were identified: • Cultural barriers related to communication about sexrelated matters.• Cultural role players in sexual education of Vatsonga adolescents.
Page 3 of 6 • Lack of material for use as reference.
• Use of distorted information by peers.

Cultural barriers related to communication about sex-related matters
Cultural taboos are a major obstacle to informed discussions about sexual and reproductive health issues, particularly with regard to young people (Cobb 2010:83).Almost all participants commented on how cultural norms related to sexual health issues form a barrier to open discussions about issues related to sexual health and consequently contraception.In the rural areas there is silent disapproval for contraceptives use amongst adolescents and therefore adolescents often use contraceptives without the knowledge of their parents.They often hide the pills from their parents and this makes them forget to take them, which leads to unwanted pregnancy.Adolescents indicated that in most cases parents who talk to their children about contraceptives are considered to be promoting promiscuity, because this seemed like giving them permission to sleep around.The finding was mostly emphasised by male participants, who indicated that they never discussed contraception with their mothers or fathers.This is supported by the following quotation from a female participant: 'You know my mother has never talked to me about the use of contraceptives; I learned about it from a friend, who just gave me the pills without giving a proper explanation.I have now given birth to a young boy.Maybe if I had gone to the clinic I would have known how to use these pills correctly and avoided pregnancy.'(Female learner, Grade11, aged 17) One male participant said: 'How do I talk to my father or mother about contraceptives?Even if I were a girl, my parents would definitely think that I am sleeping around and I would be in trouble.In fact it is taboo.I can't talk to them about this.' (Male learner, Grade 12, aged 19) Mohammad (2006:41) pointed that talking about sex or sexuality in general, is considered as taboo in some cultures.
It was further indicated that society puts a high value on girls' virginity before marriage and believe that talking openly about sexual and reproductive health might encourage unmarried youth to have premarital sex (Mohammad 2006:41).The education of boys about sexuality in general is likely to be ignored, particularly in rural areas where cultural taboos are common.

Cultural role players in sexual education of Vatsonga adolescents:
It was also found that initiation schools play the main role in educating both boys and female adolescents on issues related to sexual health.However, it was noted with great concern that none of the adolescents mentioned 'teaching about use of contraceptives' in such schools.The main activity that was mentioned was sex education through songs.This is evident in the following quotation from a male participant: Adolescents also indicated that culture determines the person who is responsible for talking to adolescents about sex.It was indicated that most of the time an aunt is the person who is given the responsibility of talking to adolescents about sexual health issue.The adolescents stated that this was ineffective as the aunt often does not stay in the same household as the adolescents.As a result, the teachings are once-off events.It was also found that during this information session, the aunt only focuses on the meaning of adolescence and avoidance of unwanted pregnancy.There is no mention of how adolescents could avoid unwanted pregnancy through the use of contraceptives.This is supported by the following quotation: 'When my aunt was called to talk to me about sexual health issues, I had just had my first menstruation, so they called her to come to talk to me.She told me about the meaning of menstruation; that I am a woman and that I should avoid sexual intercourse.She did not tell me about contraceptives and that I can get them from the clinic.I only heard about it on the radio, but it was not very clear to me as I found the topic halfway.This information is normally given to us by our peers who are not very sure about the use and effects of this particular method.' (Female learner, Grade 11, aged 17) Wood and Jewkes (1997:43) believe that adolescents, especially in the rural areas, have little knowledge about sexual and reproductive health due to the illiteracy of their mentors and social taboos.Adolescents were unaware of accompanying psychological changes that take place during and immediately after menarche.Moreover, they are often unable to discuss these issues with their parents due to social restrictions.These perceptions and misinformation often continue throughout their reproductive years.
Lack of reading material to use as reference: Adolescents, especially those living in the villages, indicated that they do not have access to information.Most adolescents indicated that most of the available information is in written form and most of their parents are illiterate.This contributes to the lack of information that parents have on issues relating to contraception.One informant said: 'It is so difficult for our parents to assist us, because most of them are illiterate and cannot understand what has been written regarding the different methods of contraception in the pamphlets.This may be contributing to their inability to give us the necessary information regarding contraception.' (Male learner, Grade 12, aged 19) It was expected of the participants to be able to read and understand health education from the pamphlets, since most of them were attending secondary school.When asked about their own responsibility regarding seeking information, boys laughed and indicated that the subject of sexuality was boring and that they would prefer movies.
Much care should be taken to make health education materials appropriate to fulfill the health information needs of the general public (Halcomb et al. 2007(Halcomb et al. :1005)).The local language should be used and illustrations provided to depict certain messages (Halcomb et al. 2007(Halcomb et al. :1005)).
The female participants in this study also indicated that most of the time materials on family planning issues were not available in the local language, which is Xitsonga.This makes it difficult for them to understand.Adolescents also indicated that posters on the walls at the local clinic are often in English and sometimes Zulu.Richter and Mlambo (2005:66) indicate that written materials are not effective for communicating with those who are unable to read their own language.This was further supported by the following quotation: 'It is very difficult to get the correct information.You know English is not our mother tongue and most of the pamphlets are in English and this often leads to misunderstanding.We should get the pamphlets in our mother tongue.This will help us understand better.' (Male student, Grade 12, aged 18) Poor health education by service providers was also cited by adolescents as another factor that contributes to poor uptake of family planning by adolescents.The adolescents indicated that health service providers are always too busy to spend some quality time with them.This makes it very difficult for the service providers to teach effectively during contact sessions.Lack of information often contributes to discontinuation of contraceptive methods, because adolescents often do not have information related to the side effects and how to deal with them.This is supported by what one adolescent said: 'I was on the injection, but I stopped because I used to have heavy bleeding and irregular menstrual periods.One day I stained my dress at school and I was so embarrassed.'(Female learner, Grade 10, aged 16) Research studies by Larsson, Eurenius and Westerling (2006:128), and Orji, Adegbenro and Olalekan (2005:257) have shown that people often learn about reproductive health and sexual behaviour, as well as obtain information on HIV and AIDS from radio dramas.Television is not yet accessible in some rural areas, although it has had a positive impact in urban areas.An important strategy used in the development of educational materials was documented by Larsson et al. (2006:159) and Orji et al. (2005:258).This included the use of bright colours with bold type, providing information in the local language and English, providing plain or bullet point lists rather than paragraphs of information, and the use of simple diagrams, artwork and drawings that are culturally appropriate (Larsson et al. 2006).
Use of distorted information by peers: Almost all the participants indicated that their main source of information was their peers.However, they also suggested that the information that they received from their peers was mostly untrustworthy and distorted.This was said to be contributing to the high pregnancy rate amongst adolescents.The following quote confirms this: 'Most of the time we as adolescents we do not go to the clinic for family planning services.We rely on one person in our group who is older to collect contraceptives from the clinic and share with us.' (Female learner, Grade 10, aged 14) This was identified as unacceptable, as the sharing of contraceptives may leave one or more person with insufficient supply for the expected period and may lead to unwanted pregnancies.Sharing of contraceptives also contributes to poor utilisation of family planning services.Another participant said: 'I have never been to the clinic for contraceptives, but I am using the pill.I get them from my older sister who normally goes there to collect them.' (Female learner, Grade 9, aged 14) Lindberg, Lewis-Spruill and Crownover (2006:83), and Anochie and Ikpeme (2003:218) indicated that close to half of the boys and girls identified mass media channels and friends as sources of useful information on contraceptives.The most frequent reasons for not seeking medical advice included not knowing where to go, uncertainty of the severity of the problem, fear of the diagnosis, fear that their parents would find out about it, and shame of speaking about the problem (Lindberg et al. 2006:77;Anochie & Ikpeme 2003:219).Lack of information sharing may lead to premature discontinuance, whilst its presence may help ensure long-term behaviour change (Delva et al. 2007:310).

Limitation of the study
The study should have been triangulated and focus group as a data collection method may have limited the extent of information sharing by participants.

Recommendations
Based on the findings of the study, recommendations for facilitating the enhanced utilisation of contraceptives by adolescents in Vhembe district, Limpopo Province were made to the Mother, Child and Women's Health unit and Department of Education in Limpopo Province, who should work collaboratively with health care providers in the development of contextual health education that includes the following: • More information on human sexuality, conception and contraception should be made available early -at primary school level -to eliminate misconceptions about contraceptives.• Adolescent should be empowered to take responsibility for the use of contraceptives, by enlightening them with proper and adequate information about their function, usage and methods.• Girls should have access to confidential counselling and quality contraceptive information and service, including emergency contraception, where appropriate.• Community workshops could be provided by collaborating with different sectors in the community such as the churches, non-governmental institutions, health workers and parents to empower adolescents about sexuality and contraception.This will enhance community participation and address issues of culture.• An effort should be made to promote active involvement and participation of boys in the reproductive health services.Parents could become partners in this campaign by playing an active role, rather than be stuck in a cultural quagmire.They could do this through education during initiation schools and participating in campaigns organised by the Department of Health.

Conclusion
Ineffective education about sexuality could influence the onset of sexual activity.Culture can have a negative impact on contraceptive use and practices.For many adolescents it was a taboo to discuss sexuality with parents and partners, and the majority of the participants could not initiate conversation about contraceptives with their parents.This clearly indicates that adolescents in villages in the Vhembe district lacked knowledge and commitment to contraceptive practices.
This study showed that friends contributed to access to sexuality information.However, this was often insufficient to help the girls adjust their sexual behaviour.Since male adolescents are perceived as having more decision-making power than their female counterparts, it is important to encourage male involvement in reproductive health programmes, as this may contribute to the reduction of the HIV pandemic, sexually transmitted infections and unwanted pregnancies.
. In this study, factors contributing to the uptake of contraceptives by teenagers were explored amongst adolescents in Vhembe District of Limpopo Province.
Limpopo Province is divided into five districts, namely Mopani, Vhembe, Capricorn, Waterberg and Sekhukhune.Vhembe is found in the far northern side of South Africa, bordered by Zimbabwe and Mozambique.Vhembe District consists of four sub-districts, which are: Thulamela, Makhado, Mutale and Musina.Vhembe District has seven hospitals, 112 clinics and eight health centres.

TABLE 1 :
Participants in focus groups showing gender distribution.