Young peoples’ interface with providers of contraceptive care: a simulated client study in two Ugandan districts

The background characteristics of facilities and providers are described elsewhere
23]. Visits to 128 facilities are included in the analysis. Two thirds of the providers
were nurse/midwives. Other providers were nursing assistant (13 %), medical doctors
(10 %), clinical officers (8 %) and others (2 %). The SCs reported that less than
a third (26 %) of the health care providers were men. The majority of the facilities
provided contraceptive services every day during day time (70 %), while others provided
services Monday to Friday (27 %) and some only on specified week days (3 %). The SCs
were received well during most of the visits (70 %).

Choice of contraceptive methods

A large number of the health care providers (71 %) chose or suggested a specific method
to the SC. Methods were recommended depending on whether the SC said she/he had children
or not. For those with children, the commonly suggested method was progestin-only
injection (54 %), followed by pills (17 %), and fertility awareness methods (13 %).
Other methods were rarely suggested. The progestin-only injection was also the most
suggested method for those with no children (40 %). The condom was mostly suggested
for those who did not have children (30 %), (Table 2).

Table 2. Contraceptive methods suggested by providers

Cost of contraceptive services

In more than two thirds (76 %) of the visits the SC paid for the services. The charges
ranged from US$ 0.25 (500 UGX) to US$ 10 (20,000 UGX). The payments were for contraceptives
(47 %), registration (18 %), consultations (9 %), family planning cards (6 %), blood
pressure check (4 %), and medications (16 %) including antibiotics, multivitamin,
mebendazole and folic acid. The SC reported paying for services in 7/34 public facilities
where services were expected to be free of charge. The cost for long- term contraceptives
(IUD and Implants) was said to be US$10 and above, while moon beads, a fertility awareness
method, was said to range between $ US 3–5 (6,000–10,000 UGX). Further, the cost of
the commonly available methods was on average US$ 0.25 for condom, US$ 0.5 (1,000
UGX) for one cycle of contraceptive pills and US$ 0.75 (1,500 UGX) for three monthly
progestin-only injections.

Waiting and consultation time

The waiting time ranged from zero to 3 h. However, in half of the visits clients waited
for less than 5 min (53 %). There was significant difference in waiting time by facility
type (p??0.001), clients waited longer during visits in public facilities. The consultations
lasted between five and 60 min. In most encounters the consulting time was 10–20 min
but there was no significant difference by facility type (Table 3). In 20 % of the visits, the general feeling expressed by the SC was that the consultation
was rushed. Long queues on the day of visit were reported in 19 % of the visits and
SCs were mixed with either general or antenatal care clients.

Table 3. Waiting and consulting time by facility type

There was a significant difference in waiting time by facility level across PFP facilities
(p?=?0.001). The waiting time in drugstores was mostly less than 5 min, and longer in
clinics (Table 4). There was no significant difference in consulting time across PFP facilities (p?=?0.32).

Table 4. Waiting and consulting time by private for profit facility levels

Client satisfaction by facility type

Overall, clients reported to be satisfied in 29 % of the consultations. During half
of the consultations the SCs said that they were treated with respect. More of the
SCs who visited PNFP facilities (8/10) were treated with respect compared to visits
in other types of facilities. The SCs said that 16 % of the facilities were dirty
at the time of the visit. The SCs considered privacy to be sufficient in 42 % of the
consultations. However, privacy during consultations differed by facility type (p?=?0.04), with privacy mostly observed in PNFP facilities followed by public facilities.
The SCs were generally dissatisfied with the services received during 44 % of the
visits to public facilities, and during 32 % of the visits to PFP facilities (Table 5). In half of the encounters, SCs stated that based on the services they had received
they would not come back to this provider for contraceptive services or recommend
the facility to others. Sex of the provider and cost had no effect of overall satisfaction.

Table 5. Client satisfaction by facility type

Qualitative analysis

The qualitative data from the narrative debriefs provided additional information.
Five major themes emerged from the narrative descriptions including; client-provider
interactions and perceptions of services received, provider behavior and attitudes,
decisions made (methods and restrictions), accuracy of advice and information given,
privacy and confidentiality, how providers treated different types of clients. These
themes are explored below.

Client- provider interaction and perceptions of services received

The SCs described hierarchal relationships with the providers. Clients’ narratives
indicated that providers frequently used medically inaccurate notions about how conception
occurred, and providers also seemed to have fears about the effects of contraception
on fertility and menstruation. Discussions between providers and clients focused on
negative experiences with contraceptive methods. Providers presented side effects
in a manner designed to scare the recipient. Providers also expressed specific fears
and doubts about potential or perceived adverse effects of contraceptives on younger

“..Injection causes bleeding, it may be non-stop, others get headaches all the time
or on and off menstrual periods, are you ready for that? …. there is tension of taking
pills every day and the moment you forget you get pregnant” (SC with a nurse/midwife
in public facility).

There were no standard approaches followed by providers in asking questions and delivering
care. Most providers asked about the age of the clients, whether they had children
or not, and the number and sex of their children. Some asked about the interest of
the partners in having a small family and if co-wives existed. Frequently, the unmarried
SCs were asked why they at present didn’t abstain from sex and ask their partners
to wait with sex till marriage. Many providers asked questions to rule out an ongoing
pregnancy, and to understand what clients knew about contraception.

Provider behavior and attitudes

Both male and female SCs reported incident of insensitive and disapproving providers.
The SCs experienced that most providers would first attend to other clients and some
providers even expressed lack of interest in contraceptive care. Some providers were
said to be defensive and complaining of shortages of supplies. In terms of communication,
unfavorable voice tone and gestures were used by the providers during some consultations.
During a few instances (four) visits female SCs experienced sexual harassment by male
health care providers.

“…The provider drew for me a female reproductive organ and explained to me how fertilization
takes place. He, however, touched my abdomen without my consent in the way that was
inappropriate while he was explaining to me and that made me feel very bad” (SC with
Doctor in PNFP facility).

During some visits, providers gave contraceptive care while doing personal or household
chores. While in some of the encounters SCs perceived that providers were too tired
and overwhelmed with the large number of clients.

The SCs reported also positive experiences such as providers giving essential information
on methods, clearing false beliefs, being friendly, helpful and attempting to address
clients’ unique needs. At times providers used unconventional approaches such as giving
a written notice for husbands to come and learn about contraceptives.

Decisions made (methods, restrictions)

The providers often made decision for the clients about methods to use or were of
the opinion that the clients should not to use contraception at all. Providers frequently
promoted a specific contraceptive method and discouraged other methods. In some cases
there were disagreements between the young person and the provider about which method
to be chosen. Providers seemed to doubt the clients’ ability to make decisions on
contraception. Furthermore, many providers gave the young people contraceptives only
after prolonged debate. Requirement for permission from the male partner was a reason
for postponing services in some visits. Some providers actively encouraged clients
to have children first or have more children before using contraception.

“…you are lucky if you have a man, first produce more kids before joining such contraceptive
methods…oh nurse what can we do?…every contraceptive method is bad- said the lab attendant
from the window. The midwife then promoted lactation amenorrhea and withdrawal method.
They both laughed at me… the moment I left, they both started talking about me, that
they are surprised such a young person wants to use contraceptives… I felt so embarrassed,
so small…I left ashamed and disappointed” (SC with a nurse/midwife, in presence of
a Lab attendant, PFP facility).

In some consultations providers expressed beliefs that some methods were not reliable
or didn’t work. Commonly providers tried to interest the SCs in methods the provider
believed worked or methods that were available at the facility.

“…Natural family planning methods such as moon beads are good, have no side effects.
Since you are a young girl you should use it, but you need to come with your husband.
Moon beads to be effective you must be in love to cooperate with partner
(SC with nurse/midwife, PFP facility).

Accuracy of advice and information given

Mostly providers were said to list the different methods and tell the clients where
to find methods not available in the facility. But there was limited or no demonstration
of the methods and how each method works. The SCs also reported that limited information
was given about follow up and also about STIs prevention. During the discussions the
use of IUDs and implants were mostly discouraged for young people. On various occasions’
providers gave inaccurate information, mostly on fertility awareness methods, side
effects caused by contraceptives, and how contraceptives work.

“…About the natural family planning, he told me about the safe days and he said that
the 3 days before the periods and the first 4 days after the periods are unsafe while
the rest are the safe days. He added that this method is not accurate and he advised
me not to use it because two eggs are released one after the other and that if one
bursts, the other remains and if one plays sex while in her periods the sperms meet
the second egg and one gets pregnant” (SC with a Nurse in PFP Drug shop).

“…Pills are good since they prevent pregnancy but since you are a student, and don’t
stay with the man, you don’t have to take the pill daily. It is better to take the
pill 1 h before having sex” (SC with provider, PFP facility).

Providers seemed to have limited knowledge on how to manage side effects. Some providers
prescribed antibiotics, multivitamin, and other drugs to treat nausea when using contraceptive
pills. Furthermore, some providers advised clients to stop the pill altogether if
she had nausea. Providers were perceived not to be confident and misconceptions were
conveyed as if they were integral part of care in some encounters.

“…The nurse welcomed me and gave me a seat inside the room. I told her that I have
two children and would like to be assisted to avoid pregnancy. She said that family
planning methods are not good to use although we have to space children. The nurse
said that the injection causes breast and cervical cancer while if the implant gets
lost in the arm one can fail to conceive forever, and the pills accumulate and they
cause fibroids on the uterus. She, however, admitted that she did not know much about
the new methods like the moon bead but recommended that I use safe days and explained
the unsafe days as the first seven days after periods while the other days are safe…”(SC
with a nurse/midwife in PFP facility).

Privacy and confidentiality

Based on SCs narratives, services during some visits were delivered with minimal privacy.
Counseling and services were often provided in presence of other clients, in some
instances other clients participated in the discussions. According to the SCs, lack
of privacy was either non-intentional where facilities were limited by physical space
or intentional where space was available but privacy still not provided. Some courteous
providers would improvise and move away from other clients to continue the discussion.
Even where there were positive experiences with information, privacy and confidentiality
were sometimes violated.

“…I was sitting in a queue with other patients when the nurse came by and asked me
what I had come for, I had to tell my story when all other patients were listening
that I was going to meet my girl friend for the first time and was scared of pregnancy
and getting HIV. She recommended a male condom and taught me briefly how to use it.
She also told me to look at the leaflet inside the condom pack to learn more about
the instructions. There was no privacy, everyone could hear us. She told me to return
in case I encountered problems” (SC with a nurse/midwife PFP facility).

Interruption from other staff was an additional limitation to privacy and confidentiality.
Further, during some of the consultations, there were interruptions by the providers’
family members or friends.

“…Provider kept moving up and down during consultation, the lab attendant came to
the window and stayed all the time, listening and interrupting our discussion or contributing
at certain points. I had no time alone with the midwife … I was embarrassed to mention
my problems with another person listening and disrupting” (SC visit to a nurse/midwife,
in PFP clinic).

How providers treated different types of clients

Providers seemed to treat clients differently according to stated age, marital status
and sex. Repeatedly, providers discouraged both sexual activity and use of contraceptives
for those who identified themselves as unmarried. In a few cases, SCs who stated teen
age were reproached or treated harshly by the providers and these clients said they
received “parent like” treatment by providers. Comments were often made on clients’
age and appearance. Some SCs reported experiences of manipulation and soliciting for
money by the providers.

“…why do you use family planning, a young girl, see the pill has made you sick, you
are going to die….Then he pulled a file and reviewed literature on family planning
methods, after reading for about 15 min he said do you have money? Are you willing
to pay me 50,000/= for the treatment of the nausea?…You see everything is here in
the book I know everything so bring the money, if you don’t have the money there is
the exit…” (SC with Clinical officer, PFP clinic).

Male SCs reported that some providers were excited that men were interested in contraceptive
services and male SCs experienced being given special treatment. On the other hand,
some providers were pro-women and encouraged use of contraception both for clients
with and clients’ with-out children. In a number of cases, those clients who reported
to be studying were given contraceptives since they were sexually active.

“…Provider explained and showed me methods on the chart. She asked me if I had ever
done HIV testing. She said that pills are not good for young people like you still
studying; they don’t protect against STIs, and also have side effects. She recommended
condoms for dual protection” (SC with nurse/midwife, public facility)