Knowledge, uptake and patterns of contraception use among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Introduction

Globally, there has been significant focus on the potential dividends to be gained by investing in and prioritising adolescent health, including sexual and reproductive health (SRH) and HIV. Although great strides have been made since the SRH historical landmark - the International Conference on Population and Development (ICPD) in 1994 - there are still multiple challenges in accessible SRH service provision for adolescents resulting in poor health outcomes^1,2. This is particularly so for adolescent girls and young women (AGYW) in sub-Saharan Africa, who continue to experience significant inequalities, challenges and unmet needs for SRH services, together with an associated increased risk of unintended pregnancies, HIV, STIs, complications related to early age pregnancy, and other SRH complications^3,4. In sub-Saharan Africa, more than 50% of rural AGYW aged 15– 24 years, and 42% of those in urban areas have been pregnant before the age of 18, with one in five new HIV infections occurring in this age group, despite representing only 10% of the population⁵. This is primarily attributed to limited information, barriers to access, constraints in exercising their SRH rights, lack of comprehensive programmes and service provision, and in many countries, framed by an unsupportive legislative and policy environment^6,7.

Although South Africa has progressive and enabling rights-based laws, policies, guidelines and programmes relating to SRH and young people^8–10, the challenges faced in relation to SRH and HIV mirrors similar trends in sub-Saharan Africa. In terms of HIV, 7% of young people age 15–24 are HIV-positive, with AGYW having a four times higher prevalence rate than their male counterparts (12% versus 3%)¹¹. The most recent South African National HIV Prevalence, Incidence, Behaviour and Communication Survey ((SABSSM V)¹² provides insight into some of the most important drivers of HIV in young people in South Africa, including early sexual debut, age disparate sex, and condom use. In terms of sexual debut in young people who have had sex, 13.6% reported having had sex before the age of 15 years. More males (aged 15–24) reported this compared to females (13.6% males vs 7.6% females). This pattern has been consistent over the previous four surveys¹².

Teenage pregnancy and its consequences are an ongoing problem^13,14. The 2016 South African Demographic and Health Survey (SADHS) found that 15.6% of South African adolescent females aged 15–19 have begun childbearing. Although adolescent pregnancy has been a major social and economic challenge in South Africa for decades, the prevalence of mostly unintended pregnancies among females aged 15–19 has remained unchanged for the last 20 years¹¹. The ramifications of unsupported teenage pregnancy are far reaching and have been well documented, and include early exiting from education¹⁵, reduced opportunities in employment and further education, socio-economic challenges, associated health risks for both the woman and the infant, increased vulnerably for STIs, HIV and gender-based violence, together with the need for social protection and support^14–17.

Contraceptive prevalence in sexually active adolescents aged 15–19 was 60.4% in the 2016 SADHS, with reliance primarily on injectables and male condoms¹¹. However consistency in condom use in this age group is poor¹² leaving young women open to unintended pregnancy. Factors contributing to poor contraceptive uptake in adolescents are cross cutting and multi-fold, and include health inequalities, limited information on contraception knowledge, barriers to accessing services, challenges with regards continuation and correct use, and gender-based violence^18–20.

Knowledge about contraception and contraceptive options is low in South African youth, this pertains particularly to both long-acting reversible contraception and emergency contraception, where, for example, only 30.9% of 15–19-year-old females knew of intrauterine devices (IUD), and 36% of emergency contraception²¹. A school-based study focusing on secondary school girl learners in grades 10 -12²² showed that while there was awareness about methods, this information was superficial - 58% knew about condoms, 50% injections, 43% oral contraceptive pills, 40% female condom and 10% IUDs, and only 17% knew about emergency contraception, but did not know how to take them. Similarly, there was a lack of information about how to take oral contraceptive pills²².

The need to use evidence to understand and design effective, responsive strategies to improve the provision of SRH services for AGYW, and more specifically, preventing teenage pregnancy and the promotion of contraception is now as urgent as ever. However, there is still a gap in research relating to adolescents' use and knowledge of contraception and related services²³. This study seeks to contribute to the evidence and understanding of the factors influencing adolescent contraception uptake. To this end, we aim to gain insight into the knowledge and uptake of contraception among grade 8 adolescents in a high HIV prevalence setting and utilise the findings to guide interventions to improve access to SRH services, inform comprehensive sexual education (CSE) and strengthen strategies to prevent unintended pregnancies, within the framework of the Integrated School Health Programme (ISHP).

Methods

Results

As previously reported^24–26,28, overall, 3432 eligible learners across 26 schools participated in the baseline survey: we included 2383 in the analysis who completed both sections of the survey. In some cases, due to lack of time, learners were unable to complete both components and were excluded from this analysis.

Table 1 provides the socio-demographic characteristics of learners, by sex and age group. As previously reported^24–26,28, of the 2383 learners, 63.1% (n=1504) were female and the majority were Black African (96.9%, n=2309). Overall, Gauteng province represented just over half of all learners (53.6%, n=1278), with more males than females (57.0% vs 51.7%, p=0.012). Almost one in five learners (18.1%, n=433) in grade 8 were older than 14 years with 5.1% 16 years and older. Under half of all learners (41.4%, n=967) reported living with both parents. Over two thirds of learners’ parents/guardians’ households were receiving government grants (67.3%, n=1498).

Just over half of learners (51.4% n=1224) reported that they were dating or in a relationship. Almost a fifth (18.3%, n=436) had ever had sex, with significant group differences by age group and sex (p=0.001). While fifteen percent of those aged 12–14 years reported ever having sex, this more than doubled (32.7%) in the 15–18 year olds. Almost two-thirds (62.8%) were aged 11–14 years when they first had sex.

Discussion

We set out to explore adolescent experience with SRH service knowledge and uptake, in particular contraception in three peri-urban settings in South Africa. The learner age profile confirmed what has been reported in other South African studies - that a considerable proportion are above the standard expected age for the grade³⁵. These learners are known to experience a number of challenges^30,35,36, and may be missing out on age-appropriate school-based comprehensive sexuality education (CSE) which would be received if they were in a higher grade.

Although over half the learners reported having accessed healthcare services in the last year, very few reported accessing SRH services specifically, and less than 5% attended a dedicated youth service. Knowledge about HIV and SRH services and rights are important elements for promoting the sexual health and development of adolescents. We found that learners who had used healthcare services commonly experienced a lack of confidentiality and the ability to ask questions, and were concerned about discrimination, this was especially so for those who mentioned healthcare workers as their primary source of SRHR information. Addressing barriers to health care is an integral part of SRH promotion³⁷, highlighting the need to improve young people’s experience of using health services which are cognisant of their rights.

Dismantling barriers, improving access, and developing effective responses to adolescent SRH and contraceptive programming is vital and there is a growing body of literature attempting to assess and define effectiveness of programmes^37,38. Studies show that high impact interventions include improved access to youth friendly services³⁹, school-based interventions⁴⁰, and in particular well designed, and age-appropriate CSE^38,41, with an emphasis on focusing on early adolescents, where patterns of behaviour are being formed⁴². In addition, the provision of quality, youth-friendly contraceptive services, sensitive to and responsive to the needs of young people is a fundamental requirement for promoting the SRH of young people⁴³, as well as services that promote informed choice and decision-making, including long acting reversible contraception in the method mix⁴⁴. A gap in programmes focussing on younger adolescents and the need to ensure that interventions include this cohort has been highlighted - for example, the Global Early Adolescent Study, which highlights the importance thereof in terms of shaping behaviour patterns, constructing gender norms, and paving the transition into older adolescence for both boys and girls^45,46. In addition, the need for interventions targeting adolescent males as well has been underscored⁴⁷.

School teachers and mothers were noted as the most common source of SRH information. This highlights two important priorities – to equip parents with the knowledge and skills to communicate effectively with their children about sex, as well as the need to provide teachers with the knowledge and skills to provide information, supported by comprehensive curricula and policies. Interventions focussing on parents have been shown to be constructive but neglected and should be included in programmatic interventions^48,49. In South Africa, the Department of Education introduced scripted lesson plans in 2010 to strengthen the SRH content and standardize implementation of the Life Orientation Curriculum⁵⁰. Despite the technical support school teachers received, including training on the delivery and content, no impact was observed on the primary outcomes of HIV knowledge, attitudes, condom use, pregnancy incidence, and genital herpes incidence⁵⁰. These findings raise the issue of whether this was due to the programme being ineffectively designed or challenges with programme implementation and lack of programme fidelity^51,52. Global evidence points to the potential benefits of CSE, if implemented adequately, in compliance with refined, evidence-guided criteria^38,53,54. The National Integrated School Health Policy⁸ outlines what areas should be included in the school health package per learner phase. Contraception is included in the two senior phases from grade 9–12, however there are no further details or guidance given. The Standard Operating Procedures for the Provision of Sexual and Reproductive Health, Rights and Social Services in Secondary Schools⁹ mention the need to counsel on the full range of available methods as laid out in the National Contraception Policy⁵⁴.

In terms of sexual experience, over half of the learners were dating or in a relationship and just under a fifth, (18.3%) had ever had sex. Two-thirds had their first sexual experience between the ages 11–14 years, and a small number below this age. Of those who had had sex, many did nothing or did not remember if a method was used to prevent pregnancy, HIV or STIs during that first sexual encounter. The importance of programmes focussing on early adolescents is reinforced, including age appropriate SRH information be provided to ensure adolescents, including very young adolescents, are equipped with the knowledge around safe sexual practices, rights and gender awareness^45,46. Interestingly, learners reported that parents were commonly involved in their decision to use contraception – this is a potential area for further research.

There was similar contraceptive ever and current use in sexually active females to previously reported data in this age group¹¹. It was interesting to note that a number of females who had not had sex in the last three months reported that they were using a contraceptive method as were some who reported never having had sex. Although this was not probed in more detail, this may reflect an intention to have sex, or prevention in the event that they have sex. This, too, is an interesting trend to further research.

Contraceptive method use was similar to national surveys in South Africa with injectables and condoms as the main methods of contraception ever and currently used in sexually active learners¹¹. This is similar to other research among AGYW in South Africa²⁰, and highlights the need to promote other available contraceptive options, particularly the use of long acting, reversible contraceptive methods which are both highly effective, do not rely on regular visits to the clinic, nor clients remembering to take them daily⁵⁵. The subdermal contraceptive implant, together with the IUD are an important part of the method choice offered to women and are supported by South Africa’s national contraceptive guidelines⁵⁴. Both are suitable for adolescents⁵⁶, and, together with short acting methods, form the basket of methods available to women in the public sector and need to be promoted^44,54. In addition, only two girls mentioned having ever used emergency contraception, and noting that only half who had had sex had ever used contraception, the need to promote emergency contraception is also an important, but underused option⁵⁷. The Standard Operating Procedures for the Provision of Sexual and Reproductive Health, Rights and Social Services in Secondary Schools⁹ clearly states the need to inform learners of emergency contraception and where it is available. These guidelines should be specifically targeted to educators involved in school SRH programme delivery.

There are several factors associated with contraceptive uptake, and these all need to be accompanied by strengthened adolescent and youth friendly services and improved outreach concerning available SRH and HIV prevention and services – for example, it was shown that some learners thought the hormonal contraception could prevent HIV and STIs, the majority of respondents reported not using protection at sexual debut, and a very low percentage used condoms at last sex. This calls for ongoing messaging concerning dual protection and the promotion of condom use and other HIV and STI prevention options, such as oral PrEP.

Knowledge, access to, and use of contraception plays a significant role in averting and decreasing millions of unintended pregnancies, births, abortions, and maternal deaths each year. Improving knowledge about contraception, including options, benefits, correct use, where and how to access reliable methods, what to do if a person has unprotected sex, as well as an understanding of their rights can help AGYW make informed decisions that can positively impact their SRH, education and psycho-social well-being^39,58.

This all serves to highlight the need for interventions that work across the ecological model - empowering individuals; promoting supportive relationships with sexual partners⁵⁹, parents, and peers and teachers and at the community level; ensuring societal norms are also addressed^60,61; as well as ensuring that this is framed by quality, accessible services, responsive to the needs of young people⁶².

Conclusion

This paper aimed to build on the body of evidence to guide school-based interventions to improve the SRH of school-going learners. Several key themes emerged. The need for age-appropriate, differentiated CSE to cater for the range of ages, and particularly for over-aged learners in South African schools was highlighted. The importance of school teachers and parents as the primary source of SRH information for learners requires an expanded, enhanced, programme to equip both teachers and parents to provide accurate, relevant and accessible information. The need for CSE to start with early grades was reinforced. The findings emphasise the importance of demand creation and outreach concerning method choice and emergency contraception, and for healthcare providers to encourage and enable informed decision-making. In addition, the paper reinforces the need for life orientation, life skills and CSE to deal with issues rooted in young people’s realities and sexual lives – such as communicating with sexual partners about safer sex, using protection at first sexual encounters (and thereafter) and the ongoing need to negotiate and use condoms. Finally, school-based interventions need to embrace integrated HIV, STI, and pregnancy prevention messages, and closer links with health services need to be constantly fostered and reinforced. These are transferrable insights and pave the way for enriching CSE and inform the implementation of expanded SRH and HIV prevention services –such as oral PrEP and other technologies into the future as well as the integration with other services.

Data availability

These data are comprised of aggregated survey responses, data codebooks and the survey tool. These data are available from:

Consent

Written informed consent for publication of the learner’s details obtained from the learners and their parents/guardian.