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

Although the Ugandan government has made impressive strides in increasing access to sexual and reproductive health (SRH) services for youth over the past 20 years, the unmet need for family planning services remains persistently high. Data from the most recent Uganda Demographic and Health Survey (UDHS) reveals that in 2016, only 10% of all women aged 15–19 and 43% of sexually active unmarried women in this age group were using a contraceptive method [1]. A quarter of women aged 15–19 had already begun having children [1]. Almost half (45%) of sexually active unmarried women aged 15–19 reported an unmet need for contraception in the UDHS. More recent data from the Guttmacher Institute suggest that the percentage of women with unmet need in this age group may be higher than 60% [1, 2]. Lack of access to family planning services has been particularly acute in Uganda’s rural areas, where the actual fertility rate is 1.3 children higher than the wanted fertility rate, and 1 in 4 females become pregnant between ages 15 and 19 [1].

The negative impact of adolescent and unwanted pregnancy should not be underestimated, as pregnancy and childbirth-related complications are a leading cause of death for females aged 15 to 19 in low-income settings [2, 3]. Pregnant adolescents experience a significantly higher rate of severe neonatal conditions such as preterm delivery, low-birthweight infants, and stillbirth. They also face an increased risk of perinatal systemic infections, eclampsia, and endometritis [1, 3, 4]. In addition, adolescent pregnancy has many economic consequences, including lower educational accomplishment and subsequent reduced vocational opportunities and financial earnings, as well as significant psychosocial consequences such as estrangement from family, depression, and even violence [5‐9]. Lack of access to SRH services can also be seen as a violation of sexual and reproductive health rights, which include the right to “decide whether, when and by what means to have a child or children, and how many children to have” [10].

Using modern family planning (FP) methods reduces adolescent pregnancy and its subsequent adverse health and socioeconomic outcomes; however, willingness and ability to access SRH services may be particularly difficult for young populations. Several general barriers to accessing FP services are prevalent in low- and middle-income countries, including long distances to health facilities, high cost, inadequate supplies, and lack of choice in FP methods [11‐13]. These barriers may be higher for youth and adolescents, who also face additional obstacles to care, such as provider refusal to deliver care and legal restrictions such as age of consent laws and requirements for spousal or parental permission for certain services [14‐16]. In addition to these health systems and policy-level barriers to access, young women in Uganda also face significant social and cultural barriers, including sexual coercion, reproductive coercion, and gender-based violence, which are prevalent in the country [17‐19]. Although the evidence is mixed, these forms of violence and coercion severely limit young women’s reproductive autonomy and may prevent them from seeking FP services and constrain their choice of FP methods [20‐23].

In addition to problems with access, acceptability and demand for services may also be low in young populations due to concerns about privacy, autonomy, and disapproving and judgmental providers [24‐26]. Large-scale population-based surveys among youth in Kenya and Zimbabwe, for example, have identified that, with regards to SRH services, adolescents cite confidentiality, short wait time, and low cost as important factors in determining their use of FP services [27].

To address these concerns and to encourage the utilization of services, global policymakers have promoted the creation of “youth-friendly” SRH services that have special features such as separate clinic hours and waiting areas for youth [28‐31]. However, there remains a relative dearth of such youth-friendly services in Uganda and elsewhere in East Africa. While Uganda’s policies allow FP services to be provided without spousal consent or parental consent for adolescents, the policies require prior education on FP method choices [32]. Providing this education to youth has been complicated by the country’s recent switch to abstinence-only sexual health education in the public school system [32, 33].

Largely absent from policy discussions about expanding youth-friendly FP services is an analysis of how this approach aligns with another strategy commonly employed by health systems in low- and middle-income countries to increase access to, and utilization of, comprehensive FP services, namely the employment of community-based health workers (CHWs) to deliver FP education and services directly to women in their communities. Such “task-sharing” CHW-based initiatives have been credited with facilitating increases in contraception uptake in low- and middle-income countries and have been central in countries that have had dramatic improvements in FP uptake, such as Ethiopia, Malawi, and Rwanda [34‐39]. In Uganda, the Ministry of Health organized CHWs into Village Health Teams (VHTs) in 2001, and since that time, CHWs have commonly been referred to as VHTs. VHTs are volunteers elected by their communities, who act as the first point of contact with the health system at the household level. They provide health education, case management of common health conditions, distribution of medicines and supplies, and referral and follow-up services for health facilities. The Ministry requires that VHTs be over the age of 18, and most programs that use VHTs also require that they be literate in the local language [40]. In 2011 VHTs were authorized to directly provide SRH services to the public, including delivering an array of contraceptive methods such as condoms, oral contraceptives, emergency contraceptives, and injectables [41, 42]. Since that time, there has been little reporting on how well VHTs have performed at meeting the needs of younger community members for FP services. Outside of Uganda, one of the few CHW FP studies that focused on young women found evidence of CHW reluctance to provide services to young, married women who had not yet had children. The authors speculate that this reluctance may have been due to a cultural expectation that young women “prove their fertility” early in marriage before spacing births [38].

Our study’s motivation is a program led by a Ugandan non-governmental organization, ACCESS-Uganda (African Community Center for Social Sustainability), in which VHTs provide community members with health education and contraceptive supplies and make referrals to primary care health centers for long-acting and permanent contraceptive methods (LAPM). Internal evaluations of the program found that beneficiaries were primarily older and married women or women who had already given birth, rather than younger, unmarried women or nulliparous but sexually active women. We, therefore, undertook this study to investigate how youth in the project area perceived VHT outreach services and to identify barriers to youth utilization of these services. We were particularly concerned to learn about youths’ desire for younger, peer VHTs, as community-based family planning programs frequently exclude adolescents from serving as CHWs [38]. Understanding how youths seeking FP services perceive the approachability of CHWs like Uganda’s VHTs is crucial for planning and managing the growing number of these initiatives. Such information is particularly crucial for programs operating in rural areas such as our study site, where CHWs may be the only easily accessible sources of comprehensive FP education and services.

This study set out to assess FP health-seeking behavior among youths in Nakaseke, Uganda, and their awareness, attitudes, and practices regarding VHT provision of FP services.

We found evidence of a significant unmet need for FP services in this sample. Most respondents were sexually active, and a significant proportion of those under 18 already had children. While 70% of youth aged 18 and under-reported having had sex, only 55% reported having ever used family planning. This evidence of an unmet need for FP services echoes the findings of previous Ugandan studies [2, 13, 49]. It underscores the work that remains to be done to ensure access to, and utilization of, FP services among youth.

Several access and utilization barriers that VHTs should address, including time, cost, and distance to FP services, were still frequently mentioned as barriers to care in this community where VHTs are active. However, the most frequently mentioned reason for not using FP was concern about side effects, particularly from LAPMs. Several sub-Saharan African studies have found that concerns about side effects and misconceptions about the effects of long-term contraceptive use are common [50‐54]. While these misconceptions and concerns are not uniquely found in VHT-based FP programs, the presence of VHTs in the study communities has not been sufficient to dispel them. Together the persistence of access barriers and misconceptions regarding contraceptive side effects reflect the finding that youth are not utilizing VHT services.

Overall, we found high awareness of VHTs services but little prior use and low willingness to use these services in the future. Despite the presence of VHTs in their communities, only half of the youth surveyed had ever talked to a VHT. When asked about FP education sources, only 20% mentioned VHTs as a source; however, we note that this low estimate could be an artifact of the survey instrument that did not allow respondents to select multiple FP education sources. Nevertheless, even though most survey respondents (84%) said that they would feel comfortable talking to a VHT about family planning, when asked where they would seek FP information if they needed it, only 9% mentioned a VHT as their first choice.

When we asked youth about their reasons for non-utilization of VHTs, we found that worries about privacy and confidentiality were the primary drivers of reluctance. Both survey and focus group respondents indicated that they were worried that VHTs would gossip or otherwise share information and that this would reveal their sexual activity to parents and might paint them as promiscuous in their peers’ eyes. Internalized stigma and the related privacy concerns are commonly cited as reasons for low use of facility-based FP service among adults and youth in sub-Saharan Africa [11, 55, 56], and privacy and confidentiality protections are frequently used as an indicator of the “youth friendliness” of facility-based services [57]. However, our findings suggest that these privacy concerns may be particularly acute for community-based FP programs that use CHWs such as Uganda’s VHTs.

Previous studies of HIV/AIDS and maternal and child health programs that use CHWs have found that community members worry about sharing information with CHWs because CHWs are seen as members of the community who are likely to pass on private information to peers and neighbors [58, 59]. Lack of trust of CHWs and fear of confidentiality breaches have been cited in many other CHW health programs and have been identified as reasons for low acceptance of CHW services [58]. These studies, like ours, find that community members may prefer to speak about sensitive matters to providers who live outside of the community and to those in formal health facilities, because these providers are seen as being more likely to protect confidentiality due to their distance, their professional codes of conduct, and their more extensive training [59].

Our respondents seemed not only to fear having sensitive information shared with the community, but also to fear judgment from VHTs themselves. 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].

Overall, prior studies and ours suggest that the main strength of CHWs—their rootedness in their communities and its norms—may also make community members reluctant to talk to them about stigmatized or socially sanctioned behavior such as premarital sex among adolescents. Several studies have documented that CHW attitudes and beliefs may reflect conservative norms that are prevalent in their communities and that CHWs are often embedded in local power structures [58, 61‐65], and provider bias has been documented as a critical factor affecting the uptake of contraceptive services, especially among adolescent, unmarried, or nulliparous women in other studies in sub-Saharan Africa [66, 67]. In these studies, parity and marriage are often positively associated with modern family planning use [66], which is consistent with our findings that married youth face less stigma in using FP services, as family planning decisions are seen as marital decisions. Youths’ awareness of possible provider bias may partially explain the reluctance to utilize VHT FP services found in our study.

One proposed means of increasing provider trust in services targeted at youth has been using peer-providers of similar age and sex. While studies have found that having CHWs of the same sex as clients increased uptake of services [61], our study finds mixed support for this intervention. Most survey respondents said that having VHTs of similar age and sex was desirable, and having VHTs of the same sex was particularly important for younger respondents. However, many focus group participants (who were older than survey respondents) preferred VHTs who were older than them because they viewed older VHTs as more professional. Several said that they preferred providers of the opposite sex. Female focus group respondents believed that male VHTs would be more likely to keep conversations private, while some male focus group respondents thought female VHTs would be more professional. Overall, our data suggest that preference for similar sex VHTs was not unanimous and, along with age matching, may be a more important consideration for younger clients rather than older youth.

Focus group responses to questions about age and sex matching highlight another theme found in provider choice discussions, namely the importance of quality of care. Preferences for a particular sex of VHT were driven not by which sex would be the most sympathetic or relatable but rather by which was seen as being the most professional. Similarly, the main reason for not preferring VHTs of similar age was concern that younger VHTs would not be as professional and knowledgeable as older VHTs. We also see in the focus groups that VHTs may be viewed as having a limited range of knowledge and skills and that this may influence decisions about whether to use their services. Quality concerns may be more pronounced among older, married, and better-educated youth, as indicated in our finding that higher education levels were associated with lower comfort using VHT services. It could be that more educated youth perceive VHTs as providing lower-quality care reserved for lower-status community members.

Despite the concerns that this study has raised about the use of CHWs to provide FP services to youth, the CHW model still has promising potential to increase access to FP services for older community members. A systematic review of 56 studies of CHW FP programs reported that 93% of studies found that CHW FP programs effectively increase the use of modern contraception, while 83% reported an improvement in knowledge and attitudes concerning contraceptives [34]. In addition, several studies have found that CHWs can improve health outcomes for HIV/AIDS and maternal and child health programs [68, 69]. Based on these findings, strong evidence exists for promoting CHW programs to improve access to FP services overall. However, the literature also suggests that there is an ongoing need to monitor and address quality of care and confidentiality concerns in CHW programs [34].

Our study finds that VHTs are a known source of FP services among older youth in Nakaseke District, but are not widely used, due primarily to privacy concerns surrounding the use of stigmatized FP services. Our findings also suggest that the perceived trustworthiness and competence of VHTs of similar age and sex may vary by age group. Further studies to compare preferences for peer VHTs in different youth age groups may be needed to guide the recruitment and training of VHTs for community-based FP programs in Uganda.