Modern contraceptive use among female refugee adolescents in northern Uganda : prevalence, effect of peer counselling, adherence, and experiences

Background: Adolescent pregnancies have remained high globally, with the highest rates occurring in low- and middle-income countries and humanitarian settings. The high adolescent pregnancy rates have been attributed to low and inconsistent use of modern contraceptives, resulting from limited knowledge on contraception, fear of side effects, and social norms among others. The complications associated with adolescent pregnancy and childbirth are the leading cause of death among adolescents globally. There is limited knowledge on the causes of low and inconsistent use of contraception among female refugee adolescents. This study aimed to assess the use of modern contraceptives among female refugee adolescents in northern Uganda, prevalence, effect of peer counselling, adherence, and experiences.

Methods: This was a mixed-methods study employing both quantitative and qualitative techniques, carried out in Palabek refugee settlement, northern Uganda. Study I, whose objective was to determine the prevalence and factors associated with modern contraceptive use, was a cross-sectional study conducted from May to July 2019. It involved 839 female refugee adolescents aged 15 to 19 years. Study II, to determine the effect of peer counselling on acceptance of modern contraceptives among female refugee adolescents, was a randomized, controlled, single-blind, superiority trial with two-parallel groups in a 1:1 allocation ratio. It was carried out from May to July 2019 and involved 588 female refugee adolescents aged 15 to 19 years. Study III had an objective to determine the rates and predictors of adherence to modern contraceptives among female refugee adolescents in northern Uganda. This was a prospective single cohort study, nested into the randomized controlled trial. It involved 272 female adolescents aged 15 to 19 years who were new starters of modern contraceptives. They were followed up for a period of six months from May 2019 to January 2020, with follow-ups done at one, three and six months. Study IV was conducted to explore the contraceptive experiences of female refugee adolescents in northern Uganda. It was an explorative qualitative study carried out from June to October 2021, among 24 purposively selected adolescents aged 16 to 19 years who were current or previous users of modern contraceptives.

Results: The prevalence of modern contraceptive use was 8.7% (95% CI: 7.0 to 10.8), with the most commonly used method being the injectable [42.5% (95% CI: 31.5 to 54.3)]. The commonest reasons for non-use of contraception were fear of side effects (39.3%), prohibition from the partner (16.4%), and the wish to become pregnant (7.0%). The factors associated with non-use were being married (OR = 0.11, 95% CI: 0.04 to 0.35, p < 0.001), or cohabiting (OR = 0.43, 95% CI: 0.20 to 0.93, p = 0.032) and having an older partner (OR = 0.93, 95% CI: 0.86 to 0.99, p = 0.046) (Paper I). Peer counselling had a positive effect on acceptance of modern contraceptives among adolescents; peer counselled adolescents were 24% more likely to accept a contraceptive method than those who received routine counselling (PR: 1.24, 95% CI: 1.03 to 1.50, p = 0.023). The only factor identified to be associated with acceptance was partner’s education (PR: 1.45, 95% CI: 1.02 to 2.06, p = 0.037 for tertiary versus lower education). The most reported reasons for non-acceptance were fear of side effects and partner prohibition (Paper II). Adherence to contraception was low and reduced over time. Only 44% of the participants were still using a contraceptive method by the end of the six months follow up. Side effects (57.1%) and partner prohibition (23.8%) were the most reported reasons for discontinuation. Users of LARCs were more likely to adhere to contraception than the users of SARCs (OR: 3.37, 95% CI: 1.914-5.937, p=<0.001) (Paper III). Regarding the experiences of contraceptive use, the respondents’ experiences revealed that their close relations significantly influenced contraceptive use and decision making. The close relations, which included peers, partners, and parents/guardians influenced use by either supporting, discouraging or prohibiting contraceptive use, guided by the established social norms. Those who encouraged use did so because of their awareness of the benefits of contraception, while those who discouraged use did so because of their opinions or misconceptions and cultural norms regarding contraception among adolescents. Schools and health care institutions also played a role in shaping attitudes and fostering motivation for contraceptive use (Paper IV).

Conclusion: The use of modern contraceptives among female refugee adolescents was very low, leaving the participants vulnerable to adolescent pregnancy and associated complications. Participants who were least likely to use contraceptives are those who were married or cohabiting and those who had older partners. This is indicative of gender-power imbalances in fertility decision making among adolescents. Peer counselling proved effective in increasing same-day acceptance of modern contraceptives among the participants. It should therefore be included in future interventions to prevent adolescent pregnancy. Adherence to contraception was low, especially among participants who were using short-acting reversible contraceptives (SARCs). This rendered them more vulnerable to unintended pregnancy. The fear of side effects and partner prohibition stood out as the factors that continue to impede contraceptive use among refugee adolescents. Future interventions should focus on how to address these challenges. The interpersonal relationships of the respondents (peers, partners and parents) and institutions like schools and health care greatly influence the use of contraception among the respondents. We recommend that they are involved in future interventions to reduce adolescent pregnancy.

List of scientific papers

I. Bakesiima R, Cleeve A, Larsson EC, Tumwine JK, Ndeezi G, Gemzell-Danielsson K, Nabirye RC, Beyeza-Kashesya J. Modern contraceptive use among female refugee adolescents in northern Uganda: prevalence and associated factors. Reprod Health. 2020 May 20;17(1):67.
https://doi.org/10.1186/s12978-020-00921-y

II. Bakesiima R, Beyeza-Kashesya J, Tumwine JK, Chalo RN, Gemzell-Danielsson K, Cleeve A, Larsson EC. Effect of peer counselling on acceptance of modern contraceptives among female refugee adolescents in northern Uganda: A randomised controlled trial. PLoS One. 2021 Sep 2;16(9):e0256479.
https://doi.org/10.1371/journal.pone.0256479

III. Bakesiima R, Gemzell-Danielsson K, Beyeza-Kashesya J, Ayebare E, Cleeve A, Larsson EC, Nabirye RC. Adherence to modern contraceptives among female refugee adolescents in northern Uganda: a prospective single cohort study. [Submitted]

IV. Bakesiima R, Larsson EC, Gemzell-Danielsson K, Nabirye RC, Beyeza-Kashesya J, Cleeve A. ‘They stopped laughing when they realised the importance of contraception’: a qualitative study to explore contraceptive experiences of female refugee adolescents in northern Uganda. [Manuscript]