Based on the socio-ecological model that guided the study analysis, the results are presented below according to the different themes as described in the sub-section on data analysis.
Individual level barriers of adolescents’ access to contraceptive services
Individual level factors that limit access to contraceptives for adolescents include lack of awareness and poor knowledge of contraception, fear of side effects of contraceptives, inability to afford cost of services, timidity, nonchalance and low self-esteem. Each of these factors is discussed in detail below.
Poor awareness and knowledge of contraception
Respondents were of the opinion that awareness of contraceptives and their sources is low among adolescents and this constitutes a major barrier to their utilization of contraceptive services. This poor awareness was linked to low level of education among adolescents in Ebonyi state.
“Some of them (adolescents) are not aware of contraceptives and those aware don’t know where to get it from or which one will be good for them” (IDI- state program manager, female).
“.......because when somebody is educated they should be able to know that as a girl, I need to do this … I need to do that; even when your parents did not tell you, you must have learnt it (contraceptive methods) somewhere” (IDI- state program manager, female).
Fear and experience of side effects of contraceptives
Respondent’s opined that adolescent’s fear of side effects associated with some contraceptive methods is a barrier to utilizing contraceptives. Such side effects often reported by some adolescents as a contributory factors discouraging them from using some modern contraceptive methods include prolonged or irregular menstrual cycle and weight gain/loss.
Inability to afford the cost of contraceptives and contraceptive service
The direct and indirect costs associated with accessing contraceptive services from formal health service providers were perceived as barriers to accessing contraceptive services. Specific mention was made of lack of funds for medical expenses and transportation fare to facilities. Although contraceptives commodities are provided free of charge in public health facilities, some remote areas have not been reached with contraceptive services and adolescents either have to pay for these commodities from private facilities or travel far distances to public facilities.
“Adolescents may not have the fund for his/her medical expenses … … Most of the communities are far from health facilities” (IDI- state policy maker, female).
“Adolescents whose homes are in the remote areas find it difficult to go for SRH program. And in some of these seminars you are required to register and pay certain amount. People who don’t have money, will lose the opportunity of benefiting from such programs” (FGD- community village heads, male, farmer).
Timidity, nonchalance and low self-esteem
Adolescents were reported to have low self-esteem and lack confidence to seek contraceptive services. They were also perceived to be too shy to openly discuss contraception with health workers. Some respondents perceived adolescents as having an off-hand attitude to prevention of unwanted pregnancy, hence the low demand for contraceptives.
“They (adolescents) feel shy to open up and say the situation of things for them” (IDI- community leader, male)
“Adolescents have nonchalant attitude/behaviour towards getting the right information and services because even when the government organizes free seminars many of them don’t go. They feel less concerned” (FGD- community village heads, Male, trader).
Interpersonal barriers of adolescents’ access to contraceptives (family-related factors)
Interpersonal (family-related) barriers to contraceptive access for adolescents include poor parent-child communication of sexual and reproductive health matters and negative perceptions about adolescent sexuality education including information on contraceptives.
Poor parental communication of sexual and reproductive health matters with adolescents
There is a ‘culture of silence’ among parents on discussing sexual and reproductive health matters with adolescents. Some parents are not educated themselves on adolescent sexuality and do not understand why they need to discuss sexuality with their adolescents. Some other parents have negative perceptions and attitudes towards adolescents receiving sexuality education and contraceptive information and services. Hence, they tend to shy away from having these discussions.
“Most of the time, we parents shy aware from telling our children the truth like if you sleep with a man you can get pregnant. Because we fail in this responsibility, they hear it from their peers and most of the time they get the wrong information” (IDI- state policy maker, male).
Common reasons given for avoiding or delaying such discussions with adolescents include, i) adolescents are too young and their innocence should be protected, ii) discussions will lead to promiscuity, and iii) discussing contraception with adolescents is morally wrong.
“Even up till now, families think that it is an abomination to talk about contraceptives among adolescents because it will make them, especially the girls … to be wayward or promiscuous; that if you start telling them how to prevent pregnancy, it means you encourage them to start having sex” (IDI- state policy maker, male).
“Parents will not allow you educate their children. They think that you have come to corrupt their children” (FGD- community village heads, male, farmer).
These parents were said to be influenced by their religious and cultural believes about adolescents’ sexuality.
“The family that claims to be too religious can be a barrier” (IDI- state policy makers, female).
Community - cultural, societal and religious barriers to adolescents’ access to and use of contraceptives
Gendered cultural norms, societal shaming and religious intolerance preclude adolescents from accessing and using contraceptive services.
Gendered cultural norms
Adolescent girls who seek contraceptive information and services are viewed as wayward and this hinders them from using available services in public health facilities. Gendered cultural norms were reported as fostering ignorance, naivety and timidity among adolescent girls, because it limits their access to information about contraception and sources of contraceptives.
“Nigerian culture really affects many of our adolescents especially the girls from accessing sexual and reproductive health services greatly” (IDI- community leader, female).
“In our environment, a boy can go and buy condom but a girl will find it difficult because of some cultural issues” (IDI- state policy maker, female).
Cultural and religious norms
Cultural norms about early contraceptive use were perceived to be linked with poor contraceptive use among adolescents. A community leader noted that use of contraceptives among adolescents is culturally unacceptable because it will prevent pregnancy and lead to reduction in population size.
“Culturally, they look at contraceptives as a means of reducing population, and no one will like to reduce their population. That is why in our setting here, you see a man marrying so many wives to get as many children as possible” (IDI- Traditional leader, male).
Cultural and religious beliefs constitute barriers to utilization of contraceptives among unmarried adolescents. Sexual intercourse and contraceptive use among unmarried adolescents is considered a cultural taboo. Similarly, various religions advocate for total sexual abstinence among unmarried people and view pre-marital sexual intercourse as immoral. Hence, contraception for adolescents is not discussed or tolerated. This intolerance makes adolescents who need contraceptives to go into hiding for fear of being recognized while seeking information and services.
“There are things that culture does not permit a child to do, so if adolescents want to get access to contraceptive services and information, they will be feeling somehow (afraid). They will hide to get access because they know that our culture is against it (adolescents accessing contraceptive information and services)” (IDI- state policy maker, female)
“In religious settings, they look at it (contraceptive services) as a sin” (IDI- Traditional leader, male).
“Biblically, it is wrong to tell a girl or a boy that whenever you want to have sexual intercourse go and get condom so that you will be protected from STI or pregnancy” (IDI- state program manager, female).
Societal shaming
Societal intolerance for contraceptive use among unmarried adolescents results in stigmatization and discrimination which adversely affect adolescents’ demand for contraceptives.
“Perception of the society for the young individual is that it is totally a taboo to access contraceptive services” (IDI- community leader, male).
Misconceptions about early contraceptive use
Misconceptions that contraceptive use among adolescents increases risk of infertility and limits family size were perceived to constrain adolescents from using contraceptives. Providing any form of contraceptives to unmarried adolescents was largely perceived as inappropriate because it encourages pre-marital sex and promiscuity.
“Our culture tells us that we are not to tell a child what to do to avoid unintended pregnancy. If you are saying such things, people around will see you as abnormal [frowns]” (IDI- state program manager, female).
Organizational - health system barriers to adolescents’ access to and use of contraceptives
Unfriendly and judgmental attitude of healthcare providers
Generally, respondents perceived that unfriendly and judgmental attitudes of some healthcare providers discourages adolescents from seeking contraceptive services from health facilities. Such attitudes include: yelling, scolding, and refusal/ denial of services. Adolescent are therefore reluctant to utilize contraceptive services and uncomfortable to disclose their contraceptive needs to some health workers.
“Some health workers will ask them their age and why they have come to ask for information about family planning when their mother is the head of the women organization. This makes them to shy away from accessing services from there [health facilities]” (IDI- state program manager, female).
“Let’s take for instance that an adolescent walks into the health facility and demands for a condom, everybody will shout, what are you using it for, so you are spoilt already” (IDI- state policy maker, female).
Lack of privacy and confidentiality
Provider and client consultation is a crucial first step in implementing adolescent sexual and reproductive health services. This should be done with the assurance of privacy and confidentiality of information provided. However, most respondents indicated that lack of privacy between adolescents and the health providers is a key barrier to accessing and utilizing contraceptive services. When privacy and confidentiality are not ensured it leads to lack of self-confidence and trust on health workers thereby affecting utilization rate.
“When they [adolescents] want to get access to these [contraceptive] services, they will want to trust you to keep their information confidential because they [adolescents] don’t like to be discussed. Once you don’t keep this they will run away from you or the facility” (IDI- state policy maker, female).
Weak institutional support for youth-friendly centres
Respondents opined that weak institutional support for youth-friendly centres constrains service delivery to adolescents. This is reflected in inadequate number of youth-friendly centres, unfriendly facility settings, poor funding of available centres, lack of necessary equipment and edutainment materials (such as magazines and games) that will attract adolescents to the facility, frequent stock-out of contraceptive commodities, and insufficient number of skilled/trained health workers.
Respondents highlighted that there are very few youth-friendly centres in Ebonyi state, and services provided at these centres are limited. Hence, adolescents have to travel far distances to access contraceptive services which may not be available at the time of their visit. This was believed to discourage adolescents who require these services from utilizing them
“There is adolescent and youth-friendly centre at Onueke (a community) and it is difficult for somebody at Ngbo (another community) to get access to service there because of the distance” (IDI- state policy maker, male).
The design of adolescent health units in some public health facilities were thought to be unfriendly and poorly set-out to ensure privacy for adolescents. In some public facilities, it was reported that adolescent health units were proximate to adult clinics and this makes adolescents reluctant to use such facilities for fear of being recognized and stigmatized.
“Adolescents do not like open services where adults can easily see them … they like places that are secluded” (IDI- state program manager, female).
Inadequate number of health workers who are trained to handle adolescent sexual and reproductive health was identified as a barrier to adolescents’ accessing contraceptive services from youth-friendly centres
“Even when health facilities are available, they do not have skilled providers who can manage adolescent sexual and reproductive health concerns” (IDI- state program manager, female).
Respondents also highlighted that frequent stock-outs and unavailability of preferred contraceptive methods in youth-friendly centres adversely affects access to and utilization of contraceptives by adolescents.
Societal level barriers to adolescents’ access to and use of contraceptives
Negative peer and media influence, absence of sexuality education in schools and lack of social networks in communities were highlighted as some societal level barriers to adolescents’ access to contraceptive information and services.
Influence of peer, mass and social media
These views of peers sometimes prevent sexually active adolescents from utilizing contraceptive services and respondents viewed this as negative peer influence. A public secondary school principal stated that, “In the school, peers influence adolescents negatively because they may tell them that if they go for contraceptive counseling they may be seen as spoilt people” (IDI- LGA community leader, female)
Social and mass media were also reported to have a significant influence on adolescents which could result in poor utilization of contraceptive information and services.
Incomprehensive sexuality education in school curriculum
It was reported that topics on sexuality education and contraception are not provided to secondary school students in their curriculum because of policy restrictions and societal inhibitions on teachers. Some respondents, perceived this denial of contraceptive information as wrong and unhelpful considering high levels of unintended adolescent pregnancy in the State.
“Our policy has restricted us from talking much about contraceptive needs in the school system, which already is a problem” (IDI- state program manager, male).
“Some of the times even when the teachers want to provide sexuality education they do not teach it (contraception) saying that the parent-teacher association will frown at it” (IDI- state policy maker, female).
Lack of social networks and community support
Respondents stated that there are no community structures such as ‘adolescent health support network’ to facilitate access and utilization of SRH services among adolescents. This network is believed to act as a linkage between the community and health facilities.
“I don’t think there is space for adolescents that is why they are scared when they visit health centres because they only talk about mothers, children and adults … so they feel rejected” (IDI- state program manager, female).
Macro-context barriers to adolescents’ access to and use of contraceptives
Poverty level in the society
The poor economic condition in society was reported as a barrier to adolescents’ access to contraceptive services. A community influencer stated that "poverty of the mind, poverty of the cash, poverty of the food affects adolescents …. for instance, when you tell someone to come for seminars and learn sex education, he will prefer to go to farm. Their parents will say, go to farm to produce what he will eat with his children. And when you tell somebody, come we have a program, they will say; give us money; if you are not ready to give us money, we are not coming. The person doesn’t know the importance. The person is seriously looking for money to solve their problem … " (IDI- Traditional leader, male).