Barriers and Facilitators to provision of contraceptive services to adolescents via primary healthcare facilities in Antigua: Knowledge, Attitudes & Skills of healthcare providers

2^nd Caribbean Congress on Adolescent and Youth Health

Kingston, Jamaica

20 October, 2022

​

Presenter: Adler Bynoe, UNFPA Liaison Officer for Guyana

​

Adolescents fertility rate in the Caribbean

​

​

​

​

​

(Source: PAHO, WHO, UNFPA, UNICEF. Accelerating progress toward the reduction of adolescent pregnancy in Latin America and the Caribbean. 2017)

​

Abstract of study

Background: The adolescent fertility rate for the Americas is high when compared to the global indicator (WHO, 2014). In the small islands of the Eastern Caribbean, the twin-island state of Antigua and Barbuda has one of the highest adolescent fertility rates in the Eastern Caribbean (UNFPA & CARICOM, 2014). Research evidence indicates that the vast majority of adolescent pregnancies are unintended (PAHO, 2012; UNFPA, 2013). Further, barriers to adolescents’ access to contraceptive services exist (UNFPA & CARICOM, 2014). Removal of barriers to contraceptive services for adolescents in Antigua (the most populous of the twin-island state) could help address the high rate of adolescent pregnancy.

Aim: This research examines the knowledge, attitudes and skills of healthcare providers as barriers/facilitators in the provision of contraceptive services to adolescents via primary healthcare facilities in Antigua.

Methods: Semi-structured interviews were conducted with 20 healthcare providers within primary healthcare facilities to explore healthcare providers’ knowledge, attitudes and skills and their role as barriers/ facilitators in the provision of adolescent contraceptive services via primary healthcare facilities. Analysis of the data applied an inductive approach, using thematic content analysis; allowing for themes to be identified from the interview data and correlations between such themes and the literature to be reviewed.

Results: Through the analysis of the interview data, three broad themes were identified: (1) behaviors of providers and adolescents; (2) health system; and (3) societal influences. Together, these factors work together to hinder adolescents’ access to contraceptive services.

Conclusion: Interventions, inclusive of policy changes, are needed to remove existing provider barriers to adolescent access to contraceptive services as well as aid to efforts to reduce the high adolescent fertility rate. Further research is necessary to explore the perspectives of other segments of the population, including parents.

​

​

​

​

​

���Importance of addressing this issue

​

​

​

​

​

• Addressing adolescent pregnancy in Antigua and Barbuda has clear public health implications.
• By meeting adolescents’ contraceptive needs, the number of adolescent pregnancies can be reduced (including those which end in unsafe abortions); allowing for improved maternal health (WHO, 2008).
• One can also point to the protection offered by the condom contraceptive method, in preventing the transmission of STIs.
• Reducing adolescent pregnancies will also allow for enhanced educational opportunities for adolescents through uninterrupted continued education; enabling improved emotional and psychological health of adolescents (WHO, 2008).
• Through the study, gaps in the Caribbean adolescent SRH literature can be addressed, inclusive of the absence of adequate literature that allows for an understanding of healthcare providers’ knowledge, attitudes and skills relative to adolescents’ access to and use of SRH services, inclusive of contraceptive services.

​

​

​

​

​

​

​

​

​

����Study setting

​

The study involved 20 of the 21 primary healthcare facilities on the island; covering rural, urban, mini-clinics and larger clinics.

​

​

​

​

​

​

​

​

​

​

��Sampling

• All primary healthcare facilities in Antigua were considered for inclusion in the study. The existing healthcare facilities per parish are as follows: 8 in Saint John; 4 in Saint Mary; 4 in Saint Paul; 3 in Saint Phillip; 1 in Saint Peter; and 1 in Saint George [as per map on previous slide].
• A total of twenty-one providers were identified and recruited, one from every primary healthcare facility; with a total of twenty providers actually participating in the study. No response was received from a facility in the Saint John parish; resulting in one facility not participating in the study.
• Inclusion criteria were male and female healthcare providers employed within primary healthcare facilities in Antigua and possessing at least two years of experience providing contraceptive services to adolescents; since it was felt that such individuals possess a wealth of knowledge and experience of interest to the study. Exclusion criteria constituted all healthcare providers falling outside the inclusion criteria.
• The sampling was purposive. All participants expressed their willingness to participate in the study. Given the existing staffing structure of the healthcare facilities, one in which only Nurses/ Midwifes met the inclusion criteria and one in which there are no male Nurses/ Midwifes in the community health setting, all of the participants meeting the inclusion criteria emerged as being Nurse/ Midwifes and as being female.

​

​

​

��Data collection

• To enhance data credibility, open questions were used, and technical terms were avoided.
• Initial questions were framed to facilitate the establishment of rapport between the researcher and the participant, in an attempt to decrease the likelihood of ‘socially desirable answers’ (Green & Thorogood, 2009).
• The use of probing questions allowed for additional information to be provided by participants as well as for the validation of meanings offered by participants (Weiss, 1994).
• The first section of the interview guide explored the knowledge and skills of providers in delivering adolescent contraceptive services.
• The second section of the interview guide examined providers’ attitudes towards the delivery of adolescent contraceptive services.
• The third section of the interview guide examined providers’ knowledge, attitudes and skills. As part of the interview, participants were allowed an opportunity to share their views on the topic and on any relevant issue not captured by the interview guide.
• The duration of all the interviews generally ranged from 18 to 39 minutes.

​

​

​

��Results�

Following the application of thematic content analysis to the interview data collected, three broad themes were identified:

(1) Adolescents’ and providers’ behavior;

(2) Health system; and

(3) Societal influences.

​

��Results� [Continued]

Behaviors: Provider attitudes as demonstrated by the behaviors of providers as well as the behaviors of adolescents (perceived to be partly influenced by the behaviors of providers) have the potential to hinder adolescent access to contraceptive services.

Adolescent behaviours

• Participants were unanimous in stating that adolescents generally do not visit the primary health care facilities for contraceptive services
• Participants suggested that in cases where adolescents do present themselves, the adolescent clientele is largely comprised of pregnant adolescent girls or adolescent girls who have been pregnant in the past

Healthcare providers’ behavior

• More than a quarter of participants expressed judgmental attitudes

​

​

​

��Results� [Continued]

Health system: The knowledge and skills of providers, as reflected by providers’ level of training, the protocols and guidelines enforced by providers, as well as the level of contraceptive service delivered to adolescents, has the potential to hinder adolescents’ access to contraceptive services.

• Half of the participants were of the view that adolescents up to the age of 16 years require parental consent to access contraceptive services. Responses varied among participants form the same parish as well as between parishes.
• The extreme differences in the protocols and guidelines applied to adolescent access to contraceptive services, appears to be rooted in two issues: firstly, an anomaly in the age of consent which is stated as 16 and the age of access to services which is stated as 18; and secondly, the absence of a clear adolescent SRH policy.
• Decisions on whether or not to facilitate adolescent contraceptive access is being predicated on providers’ discretion. This has led to all sorts of confusion as demonstrated by the varying practices of providers across as well as within all parishes.
• Data analysis suggests that there is a need for providers to be offered additional training to enhance their knowledge and skills; as reflected by inaccurate provider contraceptive information and providers’ acknowledgement of the absence of required skills and the absence of dedicated SRH programme within primary healthcare, across all of the parishes.
• A quarter of the participants appeared less reluctant to provide contraceptives to boys than girl
• Some providers highlighted difficulties in ensuring the availability of contraceptive supplies as hindering any provider effort to deliver adolescent contraceptive services
• Some participants pointed to the inadequate physical facilities which can hinder providers’ application of their skills in the delivery of adolescent contraceptive services

​

��Results� [Continued]

Societal influences: Analysis of the data suggests that providers are of the view that apart from the health system and the behaviours of providers and adolescents themselves, providers’ ability to apply their skills in the provision of contraceptive services to adolescents is influenced by factors within the society such as parents and schools.

• Some of the participants perceived the influence of parents as having an adverse effect on providers’ ability to apply their skills in the provision of adolescent contraceptive services; due to the perceived reluctance of parents’ to acknowledge adolescents’ contraceptive needs
• A minority of participants were very vocal in highlighting their perception of the need for their greater access to schools to allow for the application of their skills in providing adolescent access to services

​

��Implications of findings

​

​

Behaviors

• With the exception of two providers, all providers acknowledged adolescents’ reluctance to visit healthcare facilities. Such reluctance is perceived by providers as a major barrier to the provision of contraceptive services to adolescents
• Correlatively, the data suggests that interpersonal factors such as providers’ judgmental attitudes acts as a barrier to adolescents, particularly adolescent girls, access to contraceptive services via primary healthcare facilities
• The judgemental attitudes cited by approximately half of all providers does not allow for relationship building between providers and adolescents nor for provider interaction at a more personal level; thereby exacerbating barriers at the interpersonal level and fueling adolescents’ reluctance to visit healthcare facilities for SRH services

​

��Implications of findings [Continued]

Health system

• In the absence of clear protocols/ guidelines & legislation for contraceptive service provision to adolescents, providers rely on their own discretion, influenced by their own attitudes towards adolescents’ contraceptive access; which adversely affect adolescents’ access
• Age restrictions for access appear to be applied more stringently for contraceptive methods such as injectables, other than condoms
• Current training of providers appears inadequate in preparing providers to address adolescent contraceptive needs and therefore acts as a barrier to adolescent access, given that the knowledge & training influences how providers’ address adolescent contraceptive needs
• The absence of adolescent specific contraceptive training is associated with the judgemental attitudes demonstrated by participants
• The absence of a comprehensive adolescent SRH service within the primary healthcare infrastructure hinders adolescent access
• In instances where some level of adolescent access is available, barriers to the full utilization of such services exist.
• Institutional barriers appear to place greater emphasis on contraception of adolescent mothers through the integration of contraception as a component of ante-natal care offered via the primary healthcare facilities
• Many participants acknowledge seeing adolescent girls mainly at periods when they are fearful of a possible pregnancy or following a pregnancy, an indication that the primary concern of adolescent females is pregnancy prevention.
• Adolescent girls who are not yet mothers appear to face greater barriers to access, while Adolescent boys appear to have easier access to contraceptive services than adolescent girls
• Barriers to contraceptive service delivery are further enhanced by shortages of contraceptive supplies and inadequate physical facilities which are not conducive to privacy and confidentiality in some instances

​

​

​

��Implications of findings [Continued]

Societal influences

• Providers appear to value the involvement of parents in adolescent SRH and contraceptive decisions.
• Providers do need to find a balance between involving parents and maintaining adolescent confidentiality.
• Providers highlighted a need for interventions targeting parents, to enhance parents’ understanding of adolescent SRH needs and rights
• There is an absence of well-structured school based interventions
• Providers have proposed scheduled provider visits to schools to aid efforts to eliminate perceived barriers.

​

​

��Conclusion

Conclusion

• The data revealed the existence of several barriers which hinder adolescents’ access.
• The barriers identified include judgemental attitudes displayed by providers, the absence of adolescent SRH protocols and guidelines, the anomaly in the age of consent and age of access to services, the absence of provider adolescent specific contraceptive training, the absence of comprehensive adolescent SRH services, the shortage of contraceptive supplies, inadequate physical facilities, gender disparities in adolescents’ access to contraceptive services, providers perception of parents’ reluctance to acknowledge adolescent sexuality, as well as the absence of well-structured school based interventions. These barriers severely hinder adolescents’ access to contraceptive services.
• The research data indicates that provider knowledge, attitudes & skills, contributes to these barriers to adolescents’ access to contraceptive services via primary health care facilities in Antigua.

​

Delivering a world where

every pregnancy is wanted

every childbirth is safe and

every young person’s

potential is fulfilled.

​

UNFPA

​

16