Barriers faced by Ugandan university students in seeking medical care and sexual health counselling: a cross-sectional study

Globally, the youth segment of the world’s population is estimated to be over 1.2 billion [1] and about 90% of all young people live in low income countries, mainly in sub-Saharan Africa [2]. Youth form the backbone of every economy and so their health and well-being are very crucial in sustaining a nation’s development [3]. Unmet medical care and sexual health counselling needs in that sector must be taken into account when looking at the health needs of the general population. These are challenges that require attention from public health practitioners, researchers, governments, and the global community-at-large [2].

Several factors account for the high unmet needs outlined above. Young people have higher risk for sexual and reproductive health problems compared to adults [4]. Youthful exuberance affects their way of living and consequently they are more likely to require medical and sexual health counselling [5]. A study by Blum found that most deaths among young people are due to behavioural factors. In addition, the same author concluded that ineffective policies and poor health care systems escalated youth mortality [6]. Poor self-rated health status has also been associated with unmet health care needs [7]. The self-rated health status of a person at a given time was found to be a determinant of future self-rated health [8]. Contemporary health care systems deny youth adequate health care services, compared to children and adults [9]. Health care services for youth have usually been combined with health services intended for children or adults that are not youth friendly. As a result, such programs fail to deliver services earmarked for the health care needs of youth [2, 6].

The US, Canada, and Australia have made significant efforts to improve medical and sexual health counselling for young people. The strategy to provide youth-friendly health services has been to allocate specialized human resources and infrastructure. Nevertheless, inequities still exist in seeking health care among youth. In the UK, where not much emphasis has been put on the special needs of young people, they face several barriers in seeking health care, resulting in greater unmet health care and social needs for that population [10].

A Nicaraguan study found that sexual health counselling was sought by only 10% of the users of sexual and reproductive health services in that country [11]. Hesketh and colleagues have suggested that barriers faced by youth in seeking medical care and sexual health counselling are similar all over the world [12]. A study performed among female adolescent youth in the US found that the main barriers to those seeking health care were cost, transportation, lack of respect, and fear of and judgmental attitudes by providers [13]. Another study, done in Pakistan, found long waiting times, unaffordable costs, and negative attitudes on the part of providers as barriers to youth seeking health care [14]. In Sri Lanka, poor availability and limited access to existing health services, a dearth of reproductive health information, lack of confidentiality, and unfriendly attitudes have been identified as major barriers to youth seeking health care [15].

In sub-Saharan Africa countries, finding medical care and sexual health counselling by youth is very challenging. In a study conducted in Ethiopia, the gender of the service provider, the youth friendliness of the health services, and embarrassment over having a sexual health problem were the main barriers to youth in need of sexual health counselling [16]. In Tanzania, the extent to which medical care and sexual health counselling is sought by youth is very poor. Young people in that country appear to have very poor access to sexual and reproductive health and HIV/AIDS services. This is marked by the absence of youth-friendly health services and the hostile tendencies of health service providers [17]. In addition, there are legal and ethical issues confronting providers who attempt to address the health care needs of youth [9]. Moreover, the Tanzanian government decided to leave establishing youth-friendly health services to NGOs, who have been unsuccessful in making them available to the public [17].

In Uganda, the challenges for youth seeking medical care and sexual health counselling are not very different from those in other African nations. The problematic relationship between the health care system and those at the grassroots level, poorly formulated policies, and an inefficient youth health services delivery programs have been the primary factors associated with barriers to seeking medical and sexual health counselling in Uganda [18].

A study conducted in Uganda and Zambia revealed the efficacy of dealing with contextual factors in order to eliminate barriers to sexual health counselling. These factors included culture and its impact on attitudes towards sexuality; the accessibility of sexual and reproductive health services for youth; and the role of care providers [19]. Another study that focused on university students in Uganda identified age, sex, the head of the household’s level of education, and place of origin as socio-demographic factors influencing sexual health among youth [20]. However, no study has been found that has investigated the barriers faced by Ugandan youth in seeking medical and sexual health care.

This study seeks to investigate unmet medical care and sexual health counselling needs, and barriers to obtaining such care that university students in Uganda experience. It is unique in dividing the search for health care into medical versus sexual health counselling. Unmet needs and barriers encountered in seeking medical care or sexual health counselling differ according to the context and must therefore be investigated with regards to socio-demographic characteristics such as sex, age, area of origin, and educational level of the head of the household, as well as self-rated health. Those barriers may be grouped into three categories: availability, accessibility, and acceptability of health care services [5, 21, 22]. Availability of health care services is defined both as a treatment that is not delivered at a time convenient for the consumer, and as the unavailability of professional help in the area and at the time of need. As a result, individuals experience waiting time as too long and may fail to see a doctor. Problems of cost, transportation, and competing responsibilities are linked to accessibility of health care services. Accessibility issues are commonly associated with people not having sufficient money. Acceptability of health care services refers to personal attitudes toward illness, health care providers, and the health care system [5, 21]. Responses associated with acceptability factors are: disappearance of the health problem, perception of not getting any help, respondents claim of not knowing about any good doctor, not having time, wanting to wait for a while (for medical care only), and not feeling confident with existing counselling services (for sexual health counselling only). The aim of this study is to investigate unmet medical care and sexual health counselling need, and barriers to care seeking among university students in Mbarara, Uganda.

Table 1 describes the socio-demographic factors, self-rated health, UMCN, USCN, and barriers faced in care seeking among MUST students. About 43.7% of the students came from rural areas and the rest (56.3%) came from urban and peri-urban areas. The majority of the student population (74.5%) came from families with a household head who had attained high educational level. About 14.9% of the respondents (one in five women and one in ten men) reported poor self-rated health. Two out of five students reported UMCN, while one out of five reported USCN. More women than men reported having experienced UMCN, while the inverse was true for USCN. In all, 70.4% of the students with UMCN rated acceptability of health care services as the major barrier experienced in seeking care, followed by accessibility (16.6%) and availability of health care services (13.0%). For those with USCN, the greatest barrier faced in seeking care was acceptability (72.2%), followed by availability (16.3%), and accessibility of health care services (11.5%).

Table 2 describes cross-tabular associations of UMCN and USCN with socio-demographic factors and self-rated health. About 40% of students below age 24 reported UMCN. Slightly more rural students (43.3%) reported UMCN, compared to urban/peri-urban students (40%). Students that had heads of family whose educational level was below elementary school reported slightly more UMCN (43%) than those with family heads whose education went beyond the elementary school level (40%). Three- quarters of all students with poor self-rated health status indicated having UMCN.

USCN was reported by 18% of the women and 23% of the men. Among students under age 24, 20% reported USCN. The prevalence of USCN was equally distributed among students from rural and urban areas. Students whose heads of families had educational levels beyond elementary school reported slightly more USCN (23%) than those whose heads of family had less than an elementary school education (20%). Nearly 40% of those students with poor self-rated health status also reported having USCN.

Table 3 describes the subgroup analysis of barriers faced in seeking medical care by students who reported UMCN. Among women reporting UMCN, the major barriers to obtaining medical care were acceptability (72%), accessibility (15%), and availability (13%). Men also reported a similar pattern. For them the barriers experienced in seeking medical care were acceptability (70%), accessibility (17%), and availability (13%) of health care services. Among students from rural areas, the major barriers found in seeking medical care were acceptability (65%), accessibility (22%), and availability (13%) of health care services. The results showed a significant difference (p-value 0.01) in barriers experienced in seeking care among rural and urban/peri-urban students. Of the students who indicated poor self-rated health 53%, 26%, and 21% showed acceptability, accessibility, and availability, respectively, as the major barriers faced in seeking medical care (p-value < 0.001).

Table 4 shows subgroup analysis of barriers encountered in seeking sexual health counselling by students who reported USCN. Among such women, the major barriers they experienced were acceptability (70%), followed by availability (16%), and accessibility (15%). Similarly, men who reported USCN indicated the barriers they found in seeking sexual health counselling to be acceptability (74%), availability (16%), and accessibility (10%). Among the students under age 24, the major barriers found were acceptability (74%), availability (15%), and accessibility (12%). Students with poor self-rated health (p-value 0.007) indicated acceptability (61%) as the greatest barrier encountered in seeking sexual health counselling, followed by availability (29%), and accessibility (11%).

Socio-demographic factors and self-rated health were clearly correlated with UMCN and USCN among university students in Uganda. We found strong statistical associations between UMCN and USCN and self-rated health. USCN was especially prevalent among students under age 24. The study also revealed a statistically significant association between area of origin and perceived barriers to seeking medical care.

UMCN was reported to be more prevalent among young women than men, just as in previous studies in Canada [23] and the US [2]. More men than women had USCN than UMCN. Perhaps this is because most efforts to improve sexual and reproductive health among young people are directed toward the female population.

The major barrier to seeking medical care or sexual health counselling cited by prospective student clients was the acceptability of health care services. The second barrier was accessibility (for UMCN) or availability (for USCN). Similar results were found in the overall student population as among those with poor self-rated health. The differences we found in barriers faced by those seeking medical care and sexual health counselling contrast with a study by Sibley & Glazier [21], which concluded that availability always leads acceptability and accessibility as the primary cause of unmet health care needs. In our study, acceptability of services was consistently found to be the major barrier encountered in seeking health care. It may be that people fear social, financial, or political consequences of seeking medical and sexual counselling services. Since acceptability depends on information and attitudes regarding health care services, attempts to reduce UMCN and USCN should boost confidence in health care services, encourage students to seek early treatment, and promote awareness of where they can go for their medical and sexual health needs.

Our study demonstrated a statistically significant difference (p-value 0.01) between area of origin and barriers found in seeking medical care. This stands in strong contrast to Chen & Hou’s 2002 study [22]. We found accessibility to be a stronger barrier to obtaining medical care for rural than urban or peri-urban students. In this study, not seeking medical care due to cost of services was the main indicator used to evaluate accessibility barriers medical care. Therefore it is imperative that financial barriers that intensify the rural–urban gap in UMCN be removed.

We also found that poor self-rated health correlated with UMCN, in agreement with a study that was conducted among those incarcerated for substance abuse [7]. Lower self-rated health was strongly linked to barriers experienced by students seeking medical care. Those with poorer self-rated health had more pronounced challenges with regard to accessibility and availability of health care services compared to those of their peers who reported good self-rated health. This is a crucial issue of health equity that needs to be addressed.

A unique aspect of our study was the classification of unmet health care needs into two distinct categories, UMCN and USCN, in order to reveal similarities and differences. We analyzed the barriers of availability, accessibility, and acceptability experienced by students at a university in sub-Saharan Africa who sought medical care or sexual health counselling. Our findings are supported by previous studies of unmet health care needs [2, 7, 21‐23]. The response rate in our study was high, making it easier to generalize the results.

We recommend that a) equal counselling and health care provision be made for young men and women on issues of sexual and reproductive health, b) barriers to seeking medical care and sexual counselling services be reduced by intervention aiming at boosting student confidence in health care services, encouraging young people to seek early treatment, and increasing awareness of where they can turn for services, and c) reducing waiting time, lowering cost, and increasing the availability of medical services for vulnerable groups.