Access to family planning for youth: perspectives of young family planning leaders from 40 countries

Introduction

Across Africa, Asia, Latin America and the Caribbean, children under age 15 and youth aged 15–24 comprised 40–60% of the total population in 2017¹. Many countries will see continued growth of their youth population throughout the next few decades². Adolescent pregnancy is a pressing global health challenge in these regions^3,4. The risks of maternal and infant morbidity and mortality are high for young mothers and young women also suffer disproportionate consequences of unsafe abortion³. Unintended pregnancies among young people may lead to them dropping out of school, reduce future employment opportunities, and increase the risk of poverty⁵. Access to sexual and reproductive health services for youth is critical for their health and well-being and the overall successful achievement of goals laid out in the United Nations 2030 Agenda for Sustainable Development⁶.

Many countries are actively developing strategies to expand family planning (FP) access for young people, as demonstrated by the fact that nearly all Family Planning 2020 (FP2020) commitment-making countries have a focus on adolescents and youth, including through provision of youth-friendly services, free contraceptives for adolescents, and ensuring consistent commodity supplies to youth-specific facilities⁷. However, the level of detail of these commitments varies significantly. ‘Revitalized’ commitments in 2017 made by Ethiopia, Malawi, and Mozambique included plans to end child and early marriage, expand youth-friendly and school-based services, broaden method-mix availability, and include specific modern contraceptive use targets for unmarried sexually active adolescents⁸.

With the growing number of young people, there is a renewed interest in determining which FP program strategies are most effective with this population. Prior reviews have demonstrated that there is no magic bullet for reaching young people with FP information and services^9–13. Programs utilizing demand generation, engaging parents and community leaders, and training health care providers have been effective, but multi-component programming is needed⁹. In addition, more evidence is needed on other approaches designed to reach young people, including providing services outside of health facilities, such as pharmacies and drug shops, determining how to reach the most vulnerable adolescent groups, and developing standardized definitions and indicators of what constitutes ‘youth-friendly’ services to strengthen implementation of this evidence-based strategy^9,10,12. The global community has undertaken FP programming with young people since the 1990s through large initiatives such as FOCUS on Young Adults (1995–2001)¹⁴, YouthNet (2001–2006)¹⁵, PRACHAR (2001–2013)¹⁶, and, most recently, Adolescents 360 (2016-present)¹⁷. However, there are still outstanding questions regarding the most effective ways to reach young people where and when they most need sexual and reproductive health and FP information and services.

In March 2018, the Full Access, Full Choice project, in collaboration with FP2020, the Reproductive Health Unit of the World Health Organization, and the Evidence to Action project, convened a technical workshop of international organizations, United Nations agencies, and donors to identify key evidence and measurement needs to increase choice of and access to the full range of family planning methods and services for young people globally. The main output of the workshop was a global learning agenda of 41 questions. Participants ranked and identified the top two questions to be addressed in the short, medium, or long term (Figure 1)¹⁸.

Figure 1. Top learning questions for expanded family planning method choice for youth prioritized by technical workshop attendees, 2018.

Note: Learning agenda and meeting report available from here.

An important step in addressing many of these learning agenda questions is gathering young people’s voices and inputs on their lived experiences to inform strengthened programs and policies that better meet their needs. With that in mind, this paper describes the results of a survey of youth FP leaders on a selection of the learning agenda questions to guide future FP priorities and programming for young people.

Methods

Results

A total of 207 young people responded to and completed all the survey questions (49% response rate). Almost half of the respondents were aged 18–24 years (45.9%), with the remaining respondents aged 25–35 years. Approximately 60% of respondents identified as female (Table 1). Almost three-quarters of respondents (72.4%) identified their current place of residence as a country in Africa, followed by 17.2% living in Asia and smaller proportions from other parts of the world (greater participation of African respondents is likely reflective of the fact that ICFP took place in Rwanda). Forty unique countries were represented. Three-quarters of participants were engaged in family planning related activities as part of their work or school.

Table 2 presents the main influencers that respondents reported affect the use of FP among unmarried or married youth in their communities. The main influencers reported for unmarried youth were peers and friends (80.2%) and boyfriend/girlfriend (65.2%), followed by media personalities/influencers (29.0%), community health workers (23.7%), and service providers (22.7%). Married respondents were significantly more likely to state that unmarried youth were influenced by their parents than unmarried respondents and those in Asia were significantly more likely to report media personalities/influencers impacting unmarried youth than African respondents (not shown). Reported influencers of married youth FP use were significantly different. Spouse or partner was reported as the most influential (80.4%), followed by service providers (44.1%), community health workers (39.2%), and peers/friends (36.3%). A similar question was asked about influencers of contraceptive choice and contraceptive continuation and the pattern of responses was similar (see Underlying data)¹⁹.

Almost two-thirds of respondents said that it was very or somewhat hard for unmarried youth in their communities to access most FP methods (pills, injectables, and implants) besides condoms (Figure 2). Conversely, 85.7% and 78.6% of respondents said it was very or somewhat easy for married youth to get pills and injectables (significantly different than unmarried youth). Asian respondents also felt it was significantly harder for unmarried youth to get injectables than African respondents, but were more likely to state that they did not know how hard it would be for unmarried youth to get implants (not shown). Further, while 70.2% reported that it was easy for married youth to get implants, 19.7% reported that implants are still somewhat or very hard for this group to get. Condoms were rated easy to get almost equally for unmarried and married youth.

Figure 2. How easy or hard it is for unmarried and married youth to get family planning by method.

***p<0.001

Respondents also provided information about where unmarried and married youth in their communities most prefer to obtain different FP methods (Figure 3). The preferred locations varied by method and marital status. According to respondents, unmarried youth most prefer to get pills from pharmacies and chemists (62.3%), while married youth most prefer to get their pills from a hospital or health clinic (58.1%). Respondents reported that both married (84.8%) and unmarried (60.7%) youth prefer hospitals or clinics to get injectables, though nearly one fifth of respondents said that unmarried youth would like to get injectables at a pharmacy/chemist. Married respondents were significantly more likely than unmarried respondents to think that unmarried youth would get pills or injectables from a hospital or health clinic. African respondents were also significantly more likely than Asian respondents to think that hospital or clinic would be the source for pills for married youth and injectables for unmarried youth, with Asian respondents citing community-based workers and pharmacies as a source of pills and community-based workers and mobile clinics more commonly for injectables (not shown). Shops were the most commonly preferred source for condoms for both unmarried and married youth, followed by a pharmacy/chemist for both groups. Other sources for condoms suggested by small numbers of respondents included vending machines/dispensers, youth clinics, peer educators, school/university, or at community events. Finally, respondents reported that both married (89.0%) and unmarried (80.7%) youth would most prefer to get implants at the hospital or health clinic (see Underlying data)¹⁹.

Figure 3. Main preferred source of family planning for unmarried and married youth by method.

Respondents were asked what factors have the most impact on where youth in their communities seek FP, as well as open ended questions about why they thought unmarried or married youth most preferred specific sources by method. Some different reasons emerged across methods and locations for married and unmarried youth. For example, in open ended responses, respondents reiterated that unmarried youth prefer to get pills at pharmacies/chemists due to privacy, confidentiality, and less judgement than they might expect to experience at a health facility, whereas respondents reported that married youth prefer to get pills at a hospital or clinic where they are free (Table 3). Other reasons for preferring a particular source for a specific method included in Table 3 demonstrate the importance of access to and safety of injectables from ‘trained’ providers, as well as the perceived advantage of shops and pharmacies/chemists because they are discrete and there is more anonymity and less judgement passed during the business transaction of purchasing condoms.

Respondents were then asked about how youth perceive commonly used terms in FP programming (Table 4). The terms “birth spacing” (51.0%) and “contraception” (44.7%) were perceived most positively by African respondents. “Long acting and reversible contraception (LARC)” was perceived less positively, whereby 36% of African respondents reported that youth do not understand the terms and 32% reported that the term was viewed negatively. Almost two-thirds of Asian respondents reported that youth do not understand the term in their region. Married respondents were significantly more likely to report that youth do not understand the terms “LARC” or “birth spacing”, while unmarried respondents were more likely to state that youth felt negatively or neutral about “LARC” and positively about “birth spacing” (not shown). Respondents were asked to make suggestions for other possible terms for FP that might resonate with youth in their communities. A few selected responses in Table 5 demonstrate a desire for a more holistic discussion of the role of FP in the lives of youth, with many suggested terms including the removal of “family” from family planning in favor of “life” or “future” planning.

Finally, respondents were asked what areas need more prioritization to increase youth access to FP in their own words. The key themes focused on education, reducing stigma, and engaging youth. Respondents suggested that sex education should be made available throughout the school setting from high school through college. Others suggested that it was key for policy makers, programs, and providers to reach youth ‘where they are’, including making information and methods available online, through social media platforms and apps, and at places where youth gather, like clubs and colleges/universities. Respondents also believed that stigma and myths related to FP still need to be addressed, through education of community and religious leaders and support for parents to have open conversations about sex and FP with their children. Others suggested reframing FP as more holistic ‘life planning’.

Respondents said that stigma can be reduced by ensuring that FP is integrated into national health care programs, removing requirements for minors to get parental permission to access FP, and removing bans on advertising for condoms or FP on television or radio. Young people indicated that youth should be engaged at all levels of planning in order to make programs and policies that are more responsive to their needs. Other suggestions included identifying ‘younger’ providers to serve youth and increasing hours of FP clinics to make them more convenient for students. Finally, respondents suggested prioritizing high quality and reliable data collection on the perceptions and experiences of young people related to these issues and building the capacity of local organizations to ensure sustainable advocacy.

Discussion

This survey of young FP leaders gives insight into several factors influencing youth FP use. A key point was the extent to which respondents noted that FP use for unmarried youth is differentially influenced by those they are interacting with the most: their peers and friends and boyfriends/girlfriends, but also media personalities or influencers and internet and social media. As access to internet-enabled mobile phones continues to grow, efforts to reach youth with health messages have begun to shift to mobile phones and social media, with the goal, as respondents noted, of meeting them ‘where they are’²⁰. The challenge that remains is determining the best way to reach specific groups of youth, as access to mobile phones may be disproportionate across countries in urban vs. rural settings and by socioeconomic status. While many FP mobile health (mHealth) interventions to date have focused on tools to help providers with counseling^21–23, products such as Nivi, a digital marketplace for information, recommendations, and referrals for FP, could offer key opportunities to target unmarried youth with accurate information, answers to questions, and linkages to care.

Stigma related to unmarried youth’s access to FP continues to persist and is reflected by most respondents reporting that it is very or somewhat hard for unmarried youth to access pills, injectables, or implants. While expanded youth-friendly services is a stated goal by many countries, these efforts should make sure to prioritize the specific factors that respondents characterized in preferred sources: affordability, privacy/confidentiality/anonymity, discrete staff, no judgement, and staff who make clients feel comfortable. As respondents suggested, there is still work to be done to reduce stigma and provider bias in communities and health facilities. It is important that programs targeting young people do not simply train providers on youth-friendly services, but also include other individuals who interact with young people (e.g. pharmacists, teachers, and religious leaders). This will ensure that young people are surrounded by supportive adults to help facilitate their access to FP services where and when they need it. Another option to meet the desire for privacy/confidentiality and reduced stigma may include increasing access to additional methods at pharmacies/chemists and drug shops, such as subcutaneous Depo Provera (DMPA-SC), which young people could purchase and administer themselves at home or another private location^24,25.

Language was also an important focus for feedback in this survey. None of the most commonly used programmatic terms for FP were viewed particularly positively by young people, except for ‘birth spacing’ in Africa. While there may be numerous existing local translations and slang for different contraceptive methods, respondents emphasized that many of the commonly used phrases do not necessarily resonate with youth. Suggestions for different terminology focused on ‘future’ planning or ‘life’ planning, with the use of ‘family’ possibly alienating unmarried youth. These findings are in line with those of recent programs, including Adolescents 360, which has shifted their initial focus on increasing contraceptive use to an approach which supports the development of young women’s financial and entrepreneurial skills, with contraceptive use framed as a resource to help them achieve more immediate life goals²⁶. Programmatic efforts may want to focus on developing alternate, context-specific terms for FP, contraception, and LARC that resonate more closely with the lived experiences of young people in their settings. Some other programmatic examples to date include the branding associated with Diva Centres in Zambia and Future Fab in Kenya (both collaborative projects of Marie Stopes and IDEO.org)^27,28.

Limitations

This study has some important limitations. Most of the respondents were based in Africa, likely because the ICFP took place in Rwanda and those from outside Africa may have been less able to travel to and attend the meeting. Therefore, responses presented are likely more applicable to African country-contexts than other parts of the world, particularly as the types of FP methods and facilities at which they are available may vary in other contexts. However, stigma toward sexually active unmarried youth using FP exists across many countries, so it is possible that similar conclusions would be reached with a more geographically diverse sample of respondents. In addition, this study focused exclusively on respondents who were engaged with ICFP and thus is not generalizable of all young people. In addition, we are unable to determine sociodemographic differences between those who completed the survey and those who did not and there may be important differences. Since the survey was sent to people planning to attend the ICFP youth pre-conference, it is likely that all of those to whom the survey was distributed have participated in programmatic efforts directed at youth in their own countries and respondents likely felt comfortable speaking about the experiences of their communities and peers. However, we recognize that respondents' general impressions about youth may not capture the full breadth of experiences of all youth in their country and these experiences likely vary based on various characteristics including gender, race/ethnicity, or religion. This is evidenced by some discrepancies in married and unmarried respondents’ impressions of unmarried youth, for example.

Conclusions

This paper provides direct feedback from youth engaged in FP issues within their communities. Their perspectives are particularly useful as governments, policy makers and program planners seek to increase equitable access to FP for youth in their countries and operationalize their FP2020 commitments related to adolescents and youth. As reflected here, to truly reach young people, ‘youth-friendly’ services must continue to focus on meeting youth where they are, reducing stigma in communities and bias among providers, using language and programs that integrate FP into larger issues of achieving healthy lives and futures, and finally, continuously engaging a youth perspective on the success of these efforts.

Data availability