Barriers and facilitators adolescent females living with HIV face in accessing contraceptive services: A qualitative assessment of providers’ perceptions in western Kenya

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Study Justification:
This study aimed to understand the barriers and facilitators that adolescent females living with HIV face when accessing contraceptive services in western Kenya. By understanding these factors, the study sought to promote contraception within this marginalized population, which is important for their health and for preventing potential vertical HIV transmission.
Highlights:
– The study conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services-supported clinics in Homabay, Kisumu, and Migori counties in western Kenya.
– Providers identified interpersonal factors as the main barriers for adolescent females living with HIV in accessing contraception, including fear of disclosing sexual activity and challenges in seeking services without a male partner.
– Institutional factors, such as integrating contraception and HIV care and providing youth-friendly services, were identified as facilitators for contraception among these adolescents.
– The study recommended that health facilities provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.
Recommendations for Lay Reader:
– Health facilities should provide contraception services for adolescent females in a youth-friendly manner.
– Integration of contraception and HIV care can make it easier for adolescents to access contraceptives.
– Addressing the attitudes of parents, peers, and providers that equate seeking contraceptive services with promiscuity is crucial in removing barriers for these adolescents.
Recommendations for Policy Maker:
– Allocate resources to ensure health facilities provide youth-friendly contraception services.
– Support the integration of contraception and HIV care in health facilities.
– Develop and implement strategies to address the attitudes of parents, peers, and providers that hinder adolescent females living with HIV from accessing contraceptive services.
Key Role Players:
– Health facility providers
– Family AIDS Care & Education Services (FACES)
– University of California, San Francisco
– Kenya Medical Research Institute (KEMRI)
– UCSF Committee on Human Research
– KEMRI Ethics Review Committee
Cost Items for Planning Recommendations:
– Training for health facility providers on youth-friendly contraception services
– Integration of contraception and HIV care in health facilities
– Awareness campaigns to address attitudes and stigma surrounding contraception for adolescent females living with HIV

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong as it provides a clear description of the study objectives, methods, and results. The study conducted structured in-depth interviews with 40 providers at 21 clinics in western Kenya, and the transcripts were analyzed using content analysis. The findings highlight the barriers and facilitators adolescent females living with HIV face in accessing contraceptive services. The study also suggests actionable steps to improve access, such as providing youth-friendly services and integrating HIV and contraceptive services. However, the abstract does not mention the specific limitations of the study or the generalizability of the findings. To improve the evidence, it would be helpful to include a brief discussion of the study limitations and the potential implications of the findings for other settings.

Introduction: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population. Methods: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services – supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers’ perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis. Results: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services. Conclusions: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.

We administered a facility-level questionnaire between July and August 2014 to assess contraceptive service provision at 21 facilities supported by Family AIDS Care & Education Services (FACES), a collaboration between the University of California, San Francisco and the Kenya Medical Research Institute [22]. These facilities ranged from county and sub-county hospitals to dispensaries (Supplementary file 1 [23–25]). Facilities were located in Homabay, Kisumu and Migori counties in western Kenya with 27.1, 18.7 and 13.4% prevalence of HIV, respectively, the highest prevalence in Kenya [26]. Providers at these facilities provide comprehensive HIV and primary healthcare services, including contraception. The facility-level questionnaire was administered to a convenience sample of one to three health providers at each facility. The lead investigator, JMH, along with Kenyan FACES staff members, visited each facility during clinic hours, and the nurses in-charge introduced us to the HIV providers involved in contraceptive service provision at their facilities. Approximately, half of these providers further specialized in antenatal care and maternal health services. All of the health providers we approached agreed and provided written consent to participate in the study. The facility-level questionnaire included open- and closed-ended questions on provision of contraception education, counselling, commodities, referrals, provider training and clinic structure (Supplementary file 2). RCP and JMH led the questionnaire development with input from all co-authors. JMH administered the questionnaire and took field notes during the interviews. In addition, 77% of providers provided written consent to be audio recorded during the open-ended questions. All health providers were compensated for their time, equivalent to approximately US$8 (680 KSh). Content analysis was used to identify themes regarding barriers and facilitators for adolescent females living with HIV in obtaining contraceptive services. JMH and RCP independently conducted the initial coding of a sample of transcripts, and discrepancies in coding were resolved through discussion. Inductive codes were further developed as concepts emerged. Finally, codes were grouped to identify thematic trends and variant views. JMH and RCP with guidance from EA, JA and EAB organized these themes within an ecologic model [27,28]. Study data were transcribed using REDCap version 6.0, and all qualitative analyses were completed using NVivo version 10.1.1 [29,30]. The study was approved by the UCSF Committee on Human Research (CHR #13-12304) and the KEMRI Ethics Review Committee (SSC #2770).

The study mentioned focuses on understanding the barriers and facilitators that adolescent females living with HIV face when accessing contraceptive services in western Kenya. The study conducted structured in-depth interviews with 40 healthcare providers at 21 Family AIDS Care & Education Services (FACES) supported clinics. The providers’ perspectives on contraceptive service provision to adolescent females living with HIV were explored, including contraception screening and counseling, service provision, commodity security, and clinic structure.

The study found that interpersonal factors, such as fear of disclosing sexual activity and societal stigma, were the main barriers for adolescent females accessing contraception. Providers noted that adolescents fear disclosing their sexual activity to parents, peers, and providers due to the perceived repercussions of promiscuity. Seeking contraceptive services without a male partner was also seen as challenging, as some providers and community members view unaccompanied adolescents as not being serious about their relationships or having multiple concurrent relationships.

On the other hand, the study identified that institutional factors facilitated contraception for these adolescents. Integration of contraception and HIV care was found to remove the stigma associated with seeking contraceptive services. Youth-friendly services, including separate days for youth and a comfortable setting, were also seen as beneficial for adolescents seeking contraception.

Based on the study, the following recommendations can be developed into innovations to improve access to maternal health for adolescent females living with HIV:

1. Youth-friendly services: Create a more comfortable and non-judgmental environment for adolescent females seeking contraceptive services. This can be achieved by providing separate days or dedicated spaces for youth to access maternal health services.

2. Integration of services: Integrate HIV care and contraceptive services to remove the stigma associated with seeking contraceptive services. By providing comprehensive care in one setting, adolescents will feel more comfortable accessing contraception without fear of judgment or disclosure.

3. Provider training: Train healthcare providers on adolescent-friendly approaches to contraceptive counseling and service provision. This includes addressing their own biases and misconceptions about adolescent sexual activity and promoting a non-judgmental attitude towards adolescent females seeking contraception.

4. Community education: Conduct community education programs to address misconceptions and reduce stigma surrounding adolescent females accessing contraceptive services. This can involve engaging parents, peers, and community members to promote understanding and support for adolescent reproductive health.

5. Commodity security: Ensure a consistent and reliable supply of contraceptives at healthcare facilities to avoid stockouts. This will improve access to contraception for adolescent females and prevent interruptions in their reproductive health care.

By implementing these recommendations, healthcare facilities can work towards improving access to maternal health for adolescent females living with HIV and promote their overall well-being.
AI Innovations Description
Based on the study mentioned, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Youth-friendly services: Create a more comfortable and non-judgmental environment for adolescent females seeking contraceptive services. This can be achieved by providing separate days or dedicated spaces for youth to access maternal health services.

2. Integration of services: Integrate HIV care and contraceptive services to remove the stigma associated with seeking contraceptive services. By providing comprehensive care in one setting, adolescents will feel more comfortable accessing contraception without fear of judgment or disclosure.

3. Provider training: Train healthcare providers on adolescent-friendly approaches to contraceptive counseling and service provision. This includes addressing their own biases and misconceptions about adolescent sexual activity and promoting a non-judgmental attitude towards adolescent females seeking contraception.

4. Community education: Conduct community education programs to address misconceptions and reduce stigma surrounding adolescent females accessing contraceptive services. This can involve engaging parents, peers, and community members to promote understanding and support for adolescent reproductive health.

5. Commodity security: Ensure a consistent and reliable supply of contraceptives at healthcare facilities to avoid stockouts. This will improve access to contraception for adolescent females and prevent interruptions in their reproductive health care.

By implementing these recommendations, healthcare facilities can work towards improving access to maternal health for adolescent females living with HIV and promote their overall well-being.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, you can follow these steps:

1. Identify the target population: Determine the number of adolescent females living with HIV in the specific region or community where the recommendations will be implemented. This will provide a baseline for measuring the impact of the interventions.

2. Establish indicators: Define specific indicators to measure the impact of the recommendations. For example, indicators could include the number of adolescent females accessing contraceptive services, the rate of unintended pregnancies among this population, and the level of satisfaction with the youth-friendly services.

3. Collect baseline data: Gather data on the current status of access to maternal health services for adolescent females living with HIV in the target population. This can be done through surveys, interviews, or existing data sources.

4. Implement the recommendations: Introduce the recommended interventions, such as creating youth-friendly services, integrating HIV care and contraceptive services, providing provider training, conducting community education programs, and ensuring commodity security.

5. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the identified indicators. This can be done through regular surveys, interviews, or data collection from healthcare facilities.

6. Analyze the data: Analyze the collected data to assess the impact of the recommendations on improving access to maternal health. Compare the baseline data with the data collected after the implementation of the interventions to determine any changes or improvements.

7. Draw conclusions: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health for adolescent females living with HIV. Identify any gaps or areas for further improvement.

8. Make adjustments: Use the findings from the evaluation to make adjustments to the interventions if necessary. This could involve refining the implementation strategies, addressing any identified barriers or challenges, or scaling up successful interventions.

By following this methodology, you can simulate the impact of the main recommendations on improving access to maternal health for adolescent females living with HIV and make informed decisions on how to further enhance these interventions.

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