Four major themes arose from the analysis: stigma about premarital sex creates access barriers for youth, family planning providers restrict access to adolescents, family planning providers facilitate service provision for adolescents, and adult contraceptive users advocate for youth access.
Stigma about premarital Sex Creates Access Barriers for Youth
Within the theme, stigma about premarital sex creates access barriers for youth, two subthemes emerged: contraceptives are for married people as well as shame and stigma aversion.
Contraceptives are for Married People
All study participants noted the difficulties adolescents face in accessing contraceptives. The stigma surrounding adolescent contraceptive use stemmed from the cultural norm that sexual activity is confined to marriage; therefore, unmarried youth should not need to access contraceptive services.
…where I work the people we give service to are people who are married.
Nurse, female, 44 years, 6 children, Nyamasheke
I would advise her that, at the time she is married and living with a partner, then she may use contraceptives.
Condom user, 35 years, 4 children, Nyamasheke
Some felt that providing services was akin to encouraging adolescents and others to engage in sexual activity.
…I think that if a young girl went to use the contraceptive program it would be a problem. Using contraceptives is important, but for me I have a girl, and I can’t advise her to use contraceptives because it will permit her to have sex…
Condom user, 35 years, 4 children, Nyamasheke
…I will keep her secret and not tell anyone else the same age that she is using family planning because they think that we give them the freedom to have sex anytime and any day.
CHW, female, 50 years, 2 children, Musanze
Participants explained that when youth do access contraceptive services, it is assumed that they are selling sex for money.
We have youth who come to us, for example…where I work…most of the youth who come to me are prostitutes…
CHW, male, 46 years, 5 children, Musanze
…they think that people will laugh at them because they are going to use contraceptives. They laugh at them because they think that if an adolescent is using contraceptives then she is a prostitute.
Injectable user, 41 years, 5 children, Musanze
Shame and Stigma Aversion
Due to the cultural taboo, reaching out to access contraceptive services from family planning providers for youth is associated with shame and fear, therefore, youth avoid doing so.
…some young ladies are afraid to go to the health center because she thinks that if somebody sees her where they give the service of family planning, this will be shameful.
CHW, male, 42 years, 5 children, Musanze
…she is still young and has done terrible things...in our culture, as young people it is not simple to get information about family planning and to see the person who can give you contraceptives…She is ashamed to go to the health center to seek information because people can see her and she is not married.
Nurse, female, 43 years, 2 children, Musanze
Study participants more often put the barriers on the adolescents themselves instead of the social norms about premarital sexual activity creating the barriers.
But for me, I think that girls also need to use contraceptives. But the adolescents don’t see that it is acceptable for them to use contraceptives.
Injectable user, 41 years, 5 children, Musanze
The government should educate the youth to not have sex without using condoms or without having a contraceptive method. But, I think that the government does do that and gives this information to the youth, but the youth doesn’t understand it still because they don’t believe the information as much. But we will continue to teach and show them the danger of unprotected sex without using contraceptives or condoms and show them that the consequences don’t only affect your parents, but will also affect you and your whole country.
Pill user, 38 years, 3 children, Musanze
Youth also use strategies to access services in ways that conceal their identity.
…youths, they are coming in hiding.
Nurse, female, 50 years, 3 children, Nyamasheke
…people don’t come to us because they are afraid, but they go to another health center that is far away so that people won’t know them.
CHW, female, 47 years, 4 children, Musanze
She may come and hide and talk to the doctor, “I want to use a contraceptive method, but I don’t want my family or sister to know I came here for family planning service.” Nurse, female, 3 children, Nyamasheke
That’s why I think that it’s only someone who has courage who will come and ask you directly about family planning…They might ask someone for your number to call you, but they don’t want you to know that it’s her who is calling.
CHW, male, 46 years, 5 children, Musanze
Family Planning Providers Restrict Services to Adolescents
Within the theme, family planning providers restricting services to adolescents, there are three subthemes: providers stressed secondary abstinence with adolescents, limited contraceptive selection offered, and emphasized risks.
Providers Stress Secondary Abstinence with Adolescents
Most providers indicated they would provide services to adolescents.
…I have met with different girls who come to me first for advice. After they ask me for advice, I tell them they should go to the health center because it is better to use a contraceptive method than to get pregnant.
CHW, female, 61 years, 5 children, Musanze
While most providers indicated they would provide contraceptive services to adolescents, they also noted how they would emphasize secondary abstinence, using their friendly demeanor and verbal persuasion to convince youth to stop having sex.
After having friendship with this youth, that way you might be able to help her leave what she is doing because the first thing you showed her was that there isn’t a problem, you showed her friendship. After building a friendship, that’s when you might be able to help her by telling her what she’s doing is wrong, can you reduce this or that, because after she’s able to trust you we’ll be able to help her...
Nurse, female, 50 years, 3 children, Nyamasheke
If she does not agree to stop having sex, the CHW can advise her to use a contraceptive method in order to prevent unwanted pregnancy.
CHW, male, 38 years, 4 children, Nyamasheke
…the CHW will explain the good side of not seeing her boyfriend so she doesn’t get pregnant but will also tell her about using protection… She can continue her business but without bringing more kids into the world.
CHW, male, 56 years, 5 children, Musanze
Limited Contraception Selection Offered
The contraceptive methods given to youth were more limited than the universe of possible contraceptive options.
The first thing that the doctor will do is to be confidential and refer her to the youth corner service and explain to her again the methods that you offer for adolescent people. Nurse, female, 3 children, Nyamasheke
The limited selection provided to adolescents was linked to fears of infertility at later stages, when the youth was married and desiring pregnancy.
…we have to choose for her a good method that will not prevent her from getting pregnant if she wants to get pregnant at the time she gets married.
Nurse, female, 4 children, Nyamasheke
Family planning providers most often gave youth condoms and pills.
…I will give her advice “even though you have had sex at a young age, the ways of using contraception is like this…” I would give her examples and let her choose which one will work for her. But first I will teach her to stop having sex, if we see that she can’t then I will just give her condoms.
Nurse, female, 2 children, Musanze
The young girls…They tell me that they use pills…they tell me that it's the best method that the nurses choose for them, because it will not cause side effect for them.
Condom user, 38 years, 2 children, Nyamasheke
For those who are young, the teaching method is different for family planning because I am not going to have a 14 year old come to me and I will teach her about the five-year implant, because the older you are the more education you get. For young person, I will teach her about calendar method and condoms.
CHW, male, 48 years, 4 children, Musanze
Only one study participant, who was not a family planning provider, advocated for longer term method use among youth.
…I think that the youth for now the nurses need to get closer to them and give them five-year implants, I think this because in today’s society the youth does not behave well. I think that nurses should pay more attention to the youth so that the youth can avoid unwanted pregnancy.
Condom user, 37 years, 4 children, Nyamasheke
Emphasizing Risks
Providers emphasized potential risks with contraceptive use when advising adolescents, more so than with married women.
…you have to show her that she can’t keep having sex because even a family planning method can fail and she can still get pregnant using contraception. You have to show her all the negatives so she can know the things to do to take care and protect herself. CHW, female, 44 years, 5 children, Musanze
While the topic of HIV never arose when providers were discussing their interactions with married women, it was a common concern when advising adolescents.
…a CHW will welcome her just like how she will welcome another women who will come to her for help in the village without abandoning her. You see there are a lot of girls that you know in the village who are having sex, you can't abandon them instead you have to welcome them like a parent after you meet you can tell her the bad side about having sex without using protection because she can get sexual transmitted diseases.
CHW, female, 50 years, 6 children, Musanze
…when those who are not married come to ask for family planning, this makes us happy, because we help them prevent unwanted pregnancy. If she is courageous we will teach her about family planning deeply as my colleague said. We will teach her about all family planning methods until we help her to choose the best family planning method that will help her, but we also tell her that because she is not married and is having sex, she can contract HIV…
Nurse, female, 35 years, 3 children, Nyamasheke
Additionally, for pregnant youth, exposure to pregnancy during the postpartum period was treated more urgently than for married women.
…the CHW will not consider the doctor’s appointment of the six-month plan after giving birth. I will go tell the doctor she is pregnant and wants to use family planning. After giving birth the doctor will give her contraception…He will find a method before sending her home, because she can get pregnant in those six months after birth.
CHW, male, 48 years, 4 children, Musanze
…if she gives birth the doctor who takes care of her should give her a method of contraception right at that time because she may not want to come back again because she may be ashamed to come back seeking a contraceptive when she is still not married. It would be good if she got a contraceptive method after giving birth.
Nurse, female, 39 years, 5 children, Musanze
Family Planning Providers Facilitate Service Provision to Adolescents
Within the theme, family planning providers facilitate service provision to adolescents, there are three subthemes: providers are caring with youth; youth need private, confidential, and efficient services; and youth corners. Providers emphasized facilitation of service provision to youth more than barriers.
Providers are Caring with Youth
Providers also noted the care they would take with youth - how they would welcome them, make them comfortable, and treat them with kindness and respect.
The important thing is that we welcome her and behave well in front of her because when she comes to see you and tells you that she wants to use family planning, you should not look surprised or angry, but welcoming instead. Because if you look upset, she will think that her request is a big problem. So we are prepared on how to behave in that sort of situation. Treat her like your own daughter. You have to flatter her and let her know that she did the right thing for coming to see you. She is courageous because she does not care what people think about her.
CHW, male, 46 years, 5 children, Musanze
First of all they will receive her by thanking her for her decision it took for not wanting to become pregnant, because it’s not normal that…young adults will want to use family planning. So they will thank her and give her advice on methods.
CHW, female, 50 years, 5 children, Nyamasheke
Youth Need Private, Confidential, and Efficient Services
Family planning providers emphasized the need to receive youth privately as to avoid others knowing their desire to use contraception.
She will be well received. She, who doesn’t have a husband… we have a certain way to receive her, because we want to protect her privacy. We will receive her in a private place. We don’t want everyone to see that she is here for family planning.
Nurse, female, 44 years, 4 children, Nyamasheke
…there is a time when they come to the health center to get family planning but it is done in a secret way that other women can’t know that they use family planning.
Implant user, 36 years, 3 children, Nyamasheke
At the health center they must receive her in strong secret in order for her to feel like she can give more information as it is custom for those who have husbands to get family planning services.
CHW, female, 39 years, 3 children, Nyamasheke
…when they come and meet at my house, you can tell her to come back when others are not there and teach her in secret…
CHW, female, 44 years, 5 children, Musanze
Family planning providers also noted the importance of maintaining confidentiality when working with youth.
…contraception is not used by women or men only. There are even youth who use them. They have challenges of coming to see a CHW…and in that time you have to comfort them….you will take them to the health center and they will help them and you make sure it stays a secret between the doctor, CHW, and person who needs to use contraception.
CHW, male, 33 years, 2 children, Musanze
I have a girl who came to me and told me that she is having sex with her boyfriend. The first thing I did is I guaranteed her that I will keep it a secret and help her to get contraceptives. So I had a discussion with her and told her how to proceed. I had to keep her secret.
CHW, female, 61 years, 5 children, Musanze
CHWs were noted as safer providers for youth – mostly so youth can avoid the shame of accessing services publicly where married persons go for services. When youth needed to go to the health center, CHWs helped youth interact with providers at the health center, privately.
She must first go to the Community Health Workers where she can get a method like condoms. She may continue having sex with her boyfriend- it’s easier to go through the Community Health Worker because she might feel free instead of going to a clinic.
CHW, male, 59 years, 6 children, Nyamasheke
Since she is not pregnant, unmarried and a youth, she cannot go seek out contraception at the health center alone. So the CHW will speak to those family providers in confidentiality in order to help her receive contraception.
CHW, female, 51 years, 5 children, Nyamasheke
While others suggested nurses were the better option for youth due to confidentiality reasons.
…youth can’t go to community health workers because…a community health worker can break my secret and tell someone that I am using contraceptive methods and I don’t have a husband and that’s why women prefer to go to the health center to talk to the nurses because the nurses cannot break the secret.
Sterilized, 40 years, 9 children, Nyamasheke
If youth do come for services, they plead for urgent services to avoid being seen by others.
…they are seen very fast. Some people might say since she’s using family planning, she wants to continue having sex. She has to be seen very fast.
Nurse, female, 44 years, 6 children, Nyamasheke
The youth want to come without being seen by the married women. If they come, they say, “Please, doctor, please do me a favor and give me fast service so those people won’t see me.” As a nurse that’s a challenge because we don’t have enough time to discuss all the contraceptive methods they can choose from. They want to leave so fast so no married women can see them searching for contraceptive methods.
Nurse, female, 39 years, 2 children, Musanze
Youth Corners
Youth Corners, spaces in health facilities designed to be safe places for youth to access reproductive health services, were presented as a panacea for youth.
She is most welcome to the youth corner, because in the youth corner we take care of youth, both young and underage, so we can teach them about reproductive health. In the youth corner they meet only the young people so they can be comfortable with discussing with each other. They have some games to play so they can be comfortable with each other. The youth corner is located via the playgrounds so they can come for playing and a doctor can teach them about they can get pregnant if they have unprotected sex. There is no shame on her for going to the youth corner.
Nurse, female, 39 years, 2 children, Musanze
If she goes to the health center without using the ‘Youth Corner’. The provider may ask her why she did not come to the center with her husband. They may consult with her village CHW to find out more about her specific case. She may not be received well at the health center; however, if she goes to the ‘Youth Corner’ she will be received without judgment.
Nurse, female, 36 years, 3 children, Musanze
…in that corner she is able to freely express and go directly to the person she needs and doesn’t have to run into her mom, peers, or neighbor.
Nurse, female, 36 years, 3 children, Musanze
Adult Contraceptive Users Advocate for Youth Access
Within the theme of adult contraceptives users advocate for youth access there are two subthemes: advocating for youth access to contraceptives services and communicating with children about family planning.
Advocating for Youth Access to Contraceptives
Most experienced contraceptive users advocated for youth access to contraceptives – to avoid unwanted pregnancies, which are a burden to young girls as well as for the entire community.
…I think that also girls (unmarried women) need contraceptives because they are the ones who have problems right now, they have problems of getting unwanted pregnancies…
Condom user, 41 years, 5 children, Musanze
…for girls, you can’t protect them from the diseases that are outside, but you can protect them from having unwanted pregnancies. But if she uses contraceptives, it can protect her from unwanted pregnancies and reduce the problem in the village of young women having to say which man got her pregnant…This will help us to improve ourselves and give us a better future, because there will be no babies that are a burden to our daily life in the village.
Pill user, 38 years, 3 children, Musanze
Perhaps because they could directly relate to the potential consequences of unplanned pregnancies out of wedlock, experienced contraceptives users were on average far more accepting of youth using contraception than providers.
Communicating with Children about Family Planning
Experienced contraceptive users were asked about their intentions to or experience with conversing with their own children about family planning. Some women indicated comfort with these conversations, and nearly the same amount indicated discomfort.
I: How do you feel about talking about these things with your kids?
R: When I talk about these things with sex and family planning, the kids become embarrassed and it makes me also uncomfortable in front of my children. Sometimes they laugh and I tell them to laugh but it’s advice that I’m giving them. It’s not something big. I have to take care of my kids and give them the necessary advice.
Injectable user, 50 years, 5 children, Musanze
I: Do you take time to discuss family planning with your children?
P: No, it is hard to take time to talk about sex and how to use condoms with my kids. It is embarrassing.
Injectable user, 41 years, 4 children, Musanze
Among those who did talk about sex with their children, most indicated it was difficult in the beginning but the challenges decreased with time and experience.
I: Were you comfortable when you first started having these conversations with your children?
P: The first time it was hard time but now it is a normal discussion.
Condom user, 40 years, 5 children, Nyamasheke