Perceived Facilitators and Barriers to Interventions Aimed at

Perceived Facilitators and Barriers to Interventions Aimed at
Reducing Unintended Pregnancies among Adolescents in Low and
Middle Income (Developing) Countries: a Systematic Review of
Qualitative Evidence
Yeetey Enuameh MD, MSc, DrPH
1 2*
,Sarahlouise White BSc, MSc, PhD , George Adjei BSc, MSc, ,
Livesy Abokyi BA, MPH , Seth Owusu-Agyei PhD , Professor Alan Pearson AM, RN, ONC, DipNEd,
1. The Kintampo Health Research Centre Ghana: an Affiliate Centre of The Joanna Briggs
Institute P. O. Box 200, Kintampo, Ghana.
2. Drexel University School of Public Health, Philadelphia, USA,
3. Joanna Briggs Institute, Faculty of Health Sciences, the University of Adelaide, SA 5005,
* Corresponding author: [email protected]
Adolescent pregnancies are most often the result of sexual risk taking. Of the close to 14
million births among adolescents each year, between one-third and two-thirds are unplanned.
Unplanned pregnancies coupled with societal restrictions result in adolescents opting for
abortions under unsafe conditions.
The objective of this review is to present the best available evidence on perceived facilitators
and barriers to successful outcomes of programs aimed at reducing pregnancies among
adolescents in low and middle-income countries.
Inclusion criteria
Persons aged between 10 and 19 years residing in low and middle income countries, but
during the review process, those up to 25 years, adults and opinion leaders were included.
Search strategy
Page 1 The search strategy aimed to find both published and unpublished studies using qualitative
designs in English over the period of January 1960 to December 2010.
Methodological quality assessment, data extraction and synthesis
Critical appraisal of papers, data extraction and synthesis of findings were conducted using
standardized tools from the Joanna Briggs Institute Qualitative Review Instrument.
The review came up with 11 synthesized findings made up of 8 perceived barriers and 3
perceived facilitators.
Synthesized findings on both the barriers and facilitators encompassed adolescent, parental,
community, health facility, care providers, school environment and societal contributing
Implications for practice
Care providers should be respectful, ensure privacy and confidentiality to adolescents
accessing contraceptive methods.
Educational curricula should provide information on sexual and reproductive health.
Adults should be educated on the importance of their roles and of a stable home in
adolescents’ lives.
Adolescents should be educated on contraceptives’ adverse effects and counselled on stigma
associated with contraceptive use.
Adolescent females should be encouraged to go to school and achieve their goals in life.
Mothers and grandmothers should be educated on the benefits of female self-reliance.
Health educators and care providers should provide information on sources of counselling and
support for adolescents in need.
Implications for research
Further research should be conducted into the following:
Cultural/ societal norms perpetuating female subordination to males
Perception that [unprotected] sex is good for health and beauty
Misconceptions, myths and stigma associated with contraceptive use
Individual level factors that prevent early pregnancy among adolescents
Perceptions of love influencing sexual risk taking
Keywords: Adolescent, teen, teenager, young people, youth, pregnancy, unintended
Page 2 pregnancy
One of the leading causes of death of female adolescents is pregnancy (mainly due to unsafe
abortions and childbirth); females aged 15 -19 years are twice as likely to die during childbirth as
compared to those in their twenties.
(1, 4, 9)
Birth rates have declined globally since the late 1980s
among adolescents, but low and middle income countries (LMICs) have lagged behind the higher
income countries
The goal of the United Nations Millennium Development Goal (MDG) 5 is to improve Maternal Health
via a three quarters reduction in maternal mortality and achieving universal access to reproductive
health by 2015. Maternal health has on the whole improved, but maternal mortality remains high
mainly due to adolescent deaths.
aims at improving infant health.
(4, 6)
Improvements in MDG 5 are known to impact on MDG 4, which
Lack of family planning (FP) services results in about 17 million unintended pregnancies yearly in
LMICs together with their complications.
Between a third and two-thirds of approximately 14 million
adolescent births annually are unplanned.
Societal restriction could lead adolescents with
unplanned pregnancies to go for unsafe abortions, which aside being a leading cause of maternal
mortality, could result in permanent injuries to those undergoing such procedures.
Over a quarter of
an estimated 20 million unsafe abortions performed globally each year are attributed to adolescents.
Pregnancies and labour in adolescence carry higher risks of anaemia, pre/-eclampsia, excessive
bleeding, birth traumas (perineal tears, fistula, paralysis, etc.) and emotional trauma.
adolescent death at childbirth, 15 to 30 others endure varying degrees of disability.
For each
Teenage mothers in most societies drop out of school and live in poverty- a vicious cycle in some
Infants of teenage mothers could have lower birth weights, be anaemic from poor
nutrition leading to them being at a higher risk of morbidity and mortality.
Infants without living
mothers are ten times more likely to die prematurely compared to those with living mothers.
Consequences of adolescent pregnancies could result in health, educational, social, economic and
psychological costs to societies across the globe.
Urgent efforts are required at reducing pregnancy rates among adolescents in LMICs as they
contribute to high maternal mortality figures. Interventions that reduce adolescent sexual risk taking
and pregnancies do not mitigate have socioeconomic, political, cultural and reproductive health
benefits for individuals and society as a whole.
(1, 12)
Identifying perceived barriers and facilitators is
important to improving current interventions and guiding future implementation efforts.
Review objective
The review’s objective was to present the best available evidence on perceived facilitators and
Page 3 barriers to successful outcomes of programs aimed at reducing adolescent pregnancies in LMICs.
Inclusion criteria
Studies included in the review were of persons aged 10 to 19 years living in LMICs
qualitative study designs. Some other studies
and opinion leaders
and of
included persons up to 25 years of age, adults
Search strategy
The search strategy is detailed in an earlier publication
and aimed at finding published and
unpublished studies related to the objectives of the review in English between January 1960 and
December 2010. The time interval was chosen to identify relevant works in the area of adolescent
sexual and reproductive health (ASRH) before and after the spurt in research in the area during the
Assessment of methodological quality, data collection and data synthesis
Details on methodological quality assessment, data extraction and data synthesis are found in an
earlier publication
. Assessment for methodological quality, data extraction and synthesis were
performed with the help of the Joanna Briggs Institute Qualitative Assessment and Review Instrument
software (JBI-QARI).
Description of studies
Most of the studies were from communities where some earlier interventions had been carried out.
Studies mentioned interventions with multiple HIV and pregnancy prevention messages/ information
and education campaigns
(25, 29, 34)
, contraceptive availability and sexual health education in schools
, community based distribution of contraceptives
, policies and laws to prevent early entry of adolescent females into sexual relationship
and marriage
, adolescent friendly services, FP and HIV/AIDS control services
Vijana (MkV) [Good things for Young People] program
mentioned in study.
(28, 38, 39)
, ethnography
narrative research method
Tanzania, two
(28, 29)
(26, 27)
and MEMA kwa
. Some studies and no interventions
The methodologies of the studies were grounded theory
(26-28, 36)
, qualitative study
, peer group method
, descriptive cross- sectional study
and no methodology stated
Ten (10) studies were from sub-Saharan Africa, i.e. five
, readily available oral contraceptives and
(30, 31, 34, 37, 38)
(25, 29, 30, 35)
from Uganda, three
in South Africa and four from Latin America with one study each in Brazil
, Ecuador
and Nicaragua.
The studies were done between 1997 and 2010,
confirming the post-1980 (AIDS/HIV) era dramatic increase in research focused on the sexual and
Page 4 reproductive health (SRH) of young people
Perceived barriers
Alienation of adolescents from health and educational facilities that are supposed to be helping them
Adolescents feel a lack of privacy and confidentiality, with some providers being rude to them when
they sought contraceptive services within health facilities. Together with their inherent fear of being
treated disrespectfully, adolescents were hesitant in accessing FP services. Teachers in some
schools were judgmental on SRH issues making it difficult for some adolescents to seek help from
Inadequate adult supervision, care and guidance and effects of religious dogmas
Adolescent females were unable to get from their parents, guardians and adults in the community the
guidance, advice and appropriate information they needed. In place of advice, adults scared
adolescents at times and adults avoided discussions on issues of sex. Some parents were not
providing for the needs of their adolescent females. The influence of some religious dogmas resulted
in some females being overly submissive and unable to assert themselves on issues including their
SRH needs.
Negative adolescent perceptions about contraception and fear of exposure by clinic records
Some adolescents had the perception that contraception had serious adverse effects and the use of
condoms was associated with a stigma of promiscuity, unfaithfulness. In the case of a partner
suggesting condom use, it was perceived to be a tacit implication that either their partner or them
were infected with HIV. Adolescents exercised the fear that clinic documentation such as
contraceptive cards could expose them. Such situations could prevent adolescents from accessing
FP services were they to be available to them.
Sex as a conduit to health and resources
Some adolescent females perceived unprotected sex as a means to good health and beauty. Some
others saw sex as a means of making money off males; society incidentally viewed the exchange of
money for sex as a principle of reciprocity. Perceptions such as these could enhance sexual risk
taking and its many complications such as unwanted pregnancies.
Societal abhorrence of open sexual discourse and adolescents use of FP services
Information on sexual health cannot be openly delivered to adolescents for fear of corrupting them,
and they are stigmatised for accessing contraception.
Social norms that encourage adolescent females as subordinates to males
Male dominance over females is endorsed by some societies, a situation that prevents females from
being assertive and making independent decisions. Males are also seen as the sole decision makers
on issues of FP and number of children born into the family. Females in some societies are seen as
subordinates to males and to do everything to please their male counterparts. Girls who do not
perform well academically view marriage as a way of maintaining their relevance in some of these
societies. Page 5 Tacit personal and societal pressures on adolescents
Adolescents endure indirect personal (immediate family, peers) and societal (norms and values)
pressures to engage in sexual relationships and avoid pregnancy prevention measures.
Adolescents are not included in state programs providing FP services and “B” messages are not clear
and precise
State FP programs were not willing to serve adolescents; and in instances “B” messages were
ambiguous making them poorly understood influencing their uptake and utilization by young people.
Perceived facilitators
Having positive perceptions of FP practices and been assertive to protect themselves against
unplanned pregnancies
Assertive adolescents who know at which stage in a relationship to use a FP approach and have
positive perceptions about FP are more likely to be protected against unwanted pregnancies.
Care providers that address the needs of adolescents
Adolescents expect care providers to have positive attributes such as being open and friendly, whilst
addressing their needs in an environment of privacy and confidentiality. Such qualities attract
adolescents to come for care.
Protective attributes of the family and societal incentives
Supportive families who provide for the needs of adolescents are more likely to protect them from
unwanted pregnancies pregnancy, as do societal incentive packages aimed at keeping adolescents
away from pregnancies.
Discussion The review’s objective was to present the best available evidence on perceived facilitators and
barriers to programs aimed at reducing pregnancies among adolescents in LMICs. Perceived barriers
were identified in eight (8) synthesised findings, whereas facilitators were in three (3) synthesised
findings of the review.
Adolescents avoid health facilities where care providers are perceived as rude, unfriendly and
(6, 28, 30)
Young people are drawn to health facilities with a friendly approach to care
delivery as amplified in their own words: "facilities that have a face of welcome". Adolescents are also
drawn to care providers that address their needs, easily and effectively communicate with them
providing information appropriate to their needs.
Adolescents are turned away by services that do
not address their needs, care providers who are disrespectful and do not assure confidentiality and
(31, 41)
Education has been identified to keep young females away from sex and unintended
When adults are unable to provide for their needs (money, etc.), adolescents find them elsewhere
including via sexual relationships.
Families that are supportive and care for the needs of
adolescents and incentives from society could facilitate reductions in adolescent pregnancies.
Page 6 (31, 35)
Not all adults are able to perform their roles as guides and counsels for adolescents
in part due to
poor knowledge of SRH issues, and a feeling of corrupting adolescents or society's non-acceptance
of explicit sexual expressions.
(28, 30, 35)
Females’ capacity to independent decision on pregnancy
prevention for example, is curtailed by some religious beliefs and dogmas that portray female as
subservient to males.
Societal perception that condoms were for the promiscuous,
created suspicions among partners
(28-30, 37)
(25, 37)
reduced trust in relationships
as well as the fear of adverse events from contraceptive use
prevented adolescents from accessing FP services. Adolescents were fearful that clinic
records such as contraceptive cards could expose their use to those close to them.
Adolescents engaged in sex in exchange for money
justified by its reactions
and other items,
which society somehow
. Some adolescents felt unprotected sex made them healthy and beauty
exposing them to the risk of unintended pregnancies, and other health, educational, social, economic
and psychological consequences.
Open sexual discourse was prohibited by society
sexually-corrupted contrary to empirical knowledge.
excluded adolescents
spoil them.
on the presumption that adolescents would be
(43, 44)
State sponsored contraceptive programs
as they were seen as too young to use them
and that their use would
Adolescents therefore are unable to access contraceptive programs due to their fear of
societal scorn and stigma
Some societal norms make females subordinates and subservient to males, a phenomenon that
society endorses tacitly.
(30, 35)
In some of these societies, early marriage of female adolescents is
encouraged by their parents at the expense of their education
the preserve of males
, older men go after young girls
, decisions of contraceptive use are
, and some mothers and grandmothers
work assiduously to protect the status quo of male dominance over females
. These factors result
in adolescent females literally outsourcing their decision-making rights to the males, making them
vulnerable on issues like pregnancy prevention
(27, 35, 38, 39)
. Being unable to decide for themselves has
other implications in that interventions targeting females could suffer some setbacks without the
approval of their male counterparts.
Some adults pressured adolescents into sexual relationships for cultural
and other reasons
, marital
; adolescents also pressured their peers to lose their virginity
(27, 34)
, material
or prove their
. There were other adolescents who knew about pregnancy prevention measures, but
consciously avoided them to get pregnant or forgot to use them and got pregnant.
(28, 35, 36)
situations do not bode well for preventing unplanned births.
Adolescents are increasingly becoming aware of the adverse effects of teenage pregnancies on their
social development and adapting measures to protect themselves where necessary.
(37, 38)
There are
those female adolescents who ensure that their male partners use contraceptives during any sexual
encounter and would settle for nothing less.
Some males also noted they would prefer using
contraception with their female partners who they trusted to prevent pregnancies.
determination exhibited by such adolescents
The level of self-
could facilitate interventions aimed at reducing
Page 7
unwanted pregnancies.
Adolescents had different interpretations of the message on faithfulness and partner reduction.
Educational messages provided to adolescents should be simple and easy to assimilate them to
prevent ambiguous interpretations
Limitations of the review
Efforts were made to systematically search for studies relevant to the review, however some could
have been missed in the process. Also, studies included in the review were those published in the
English language and within a particular time interval. Studies in other languages and beyond the
date restrictions provided could have influenced in this review. Finally, studies excluded following the
critical appraisal process may have contained relevant information but did not meet the
methodological requirements set for the review.
The review generated 11 synthesised findings; 8 perceived barriers and 3 perceived facilitators
describing adolescent, parental, community, health facility, care provider, school environment, family
and societal factors.
Implications for practice
Care providers in health facilities and the community should be respectful, ensure privacy and
confidentiality to adolescent clients who access contraceptive services. Program directors at the
facility, district, regional and national levels of service delivery should periodically training care
providers on making their services friendly and relevant to the needs of adolescents. Teachers should
be trained on the SRH needs of adolescents and the need to accommodate their views instead of
being judgmental. The educational curricula should also be age appropriate providing the necessary
information on sexual and reproductive health of adolescents.
Care providers and program directors should organise community meetings to sensitize the adult
population on the importance of stable homes to adolescents and provide some guidance as to how
to achieve this. Adults should also be educated on the importance of their roles as advisors,
counsellors, guides in the lives of adolescents. Adults should be provided with avenues and resources
where they could access information on the needs of adolescents.
Adolescents should be educated on anticipated adverse effects of contraceptive use and what steps
to take when they experience any such effects and counselled to assuage their fears with respect to
stigma associate with contraceptive use. Care providers should also encourage adolescents to
appear at clinics without their clinic records, in accordance with the principles of adolescent friendly
health service (AFHS) delivery principles.
Education should be provided to adolescents about the various risks of unprotected sex. Adolescents
also require livelihood skills counselling to identify other sources of making money instead of seeing
sex as a medium of gaining wealth.
Page 8
There is the need for constant education and sensitization of society on the relevance of SRH
education in improving the lives of adolescents. Health educators should present contraception and
FP to the community as a means of protecting young people from SRH problems and serving as a
means to a healthy and fruitful future.
Adolescent females should be encouraged to see themselves as capable of attaining any heights, be
encouraged to go to school and learn to the best of their abilities to achieve their goals in life. Mothers
and grandmothers should be educated on the benefits of the adolescent female being self-reliant and
the impact that would have on society as a whole.
In dealing with issues of love, relationships and sexual risk taking among adolescents, de la Cuesta
and colleagues
pointed out the fact that at the moment of taking critical decisions with respect to
sexual relations with persons they loved, adolescent females had no experts to turn to. Adolescents
require education on the need to identify pressures in the lives and how to respond adequately to
them. Health educators and care providers should provide the necessary information on sources of
counselling and trusted persons in society to adolescents to whom they can call for advice in times of
distress and need. Measures should be in place to educate and enhance their skills to overcome
vulnerability and assert themselves.
Finally, the AFHS concept introduced by the World Health Organisation (WHO) and its partners,
aimed at providing accessible health care to the adolescent population, could be used to guide care
delivery and address problems related to reducing pregnancy among adolescents
(2, 46)
. AFHS, as an
approach, involves all stakeholders ensuring that adolescents are provided the required and ageappropriate care to enhance their development.
Implications for research
Cultural norms that lead to female subordination to males cut across boundaries in the developing
world. Addressing such norms go beyond one set of programs or interventions; much more research
work, both primary and secondary, should be encouraged to address this issue.
The perception among some adolescents that good sex provides good health needs some further
research into such claims.
Misconceptions, myths and stigma associated with contraceptive use influence pregnancy prevention
programmes, and much more research is required to address these issues as they affect the health of
not only adolescents but the whole population.
As individual determination facilitates intervention success, further research could be conducted into
individual level factors that prevent early pregnancy among adolescents in developing countries.
de la Cuesta et al., 2001
raised the issue of perceptions of love influencing sexual risk taking
among adolescents. This is an area that requires much more research due to its subjective nature
and its potential to throw some more light onto some of the driving forces behind adolescent sexual
Page 9
Conflict of Interest
This review was supported by a World Health Organization (WHO) grant with project no.
HQHSR1003602 and a technical support agreement (TSA) no. 200349928
Page 10
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