November is ‘Intern Spotlight Month’ here at Health Action International, when we shine a light on the interns who make tremendous contributions to our team and the work we do with their fresh perspectives, new ideas, intellect and vivacious spirit. Each week throughout the month of November, we’re introducing you to one of our interns from the past year who’ll explain the research they conducted during their internship, as well as what they gained from it. This week, allow us to introduce you to Linnea Celik, from Sweden and Turkey.
During her time at Health Action International (HAI), Linnea Celik completed a report about access to contraceptives in Uganda, as a requirement to obtain her Master’s degree from the Vrije Universiteit in Amsterdam. As part of HAI’s background research for the Health Systems Advocacy (HSA) Partnership, Linnea interviewed Ugandan key opinion leaders in sexual and reproductive health, to identify facilitators and barriers to access to contraceptives in Uganda.
Why were you interested in your chosen topic?
Sexual and reproductive health remains an issue of life or death to many people, particularly women and infants. Additionally, access to contraceptives affects individuals’ economic circumstances and life opportunities. Yet, access to contraceptives remains a neglected and stigmatised issue, not only among politicians, but also among the people who would actually benefit from better access to contraceptives.
In 2014, only three in 10 Ugandan women were using contraceptives. Out of the remaining women who were not using contraceptives, over half did not currently want to get pregnant. I wanted to find out why these women and their partners were not using contraceptives, even though there were several methods available in the public health system. Did they think that contraceptive use was harmful or inefficient? Maybe they didn’t even know about contraceptives in the first place? These were some of the questions which emerged during my literature review.
What did you discover in your research?
In my research, I discovered that most Ugandans learn about contraceptives by word-of-mouth. Information which goes through several retellings often becomes distorted or factually incorrect when it finally reaches the poorest and most rural areas. This meant that information travels slowly, especially to more remote and poorer parts of the country. Knowledge gaps were thought to be more common in people who were poor, young, poorly educated, illiterate, low-income, female, or living in rural areas. The inadequate quality of information which was available to most Ugandans had clearly generated misconceptions and fears surrounding contraceptives. Widespread misinformation about contraceptives, in interaction with social norms and values, therefore partly accounted for low contraceptive prevalence rates and uptake.
Which was your most surprising finding?
I was surprised to learn that sometimes, the main barrier to accessing contraceptives wasn’t necessarily due to a lack of knowledge or limited access to information, but rather due to social norms and expectations. For instance, the condom was well-known among Ugandans, but few were willing to use it as a contraceptive method. Many of the HIV campaigns in Uganda discouraged people from having multiple sexual partners, and if they did, encouraged them to use condoms. So people knew what condoms are, how they work, and that they protect from pregnancy and HIV. However, condoms were seen as something reserved only for “promiscuous” people, who were having sex before or outside of marriage. Therefore, married partners did not even consider suggesting condom use for fear of being suspected of cheating, and young people refrained from buying condoms for fear of getting caught planning to have sex.
Why did you want to do your internship at HAI, and what did you gain from it?
I first heard of HAI when Tim Reed, the executive director, came to one of our classes to hold a lecture about pharmaceutical promotion. The topic was pretty new to me, so the lecture was a real eye-opener, and this sparked my interest in HAI’s other projects. At the end of the lecture, a student asked him about internship opportunities. Tim responded that the HAI team values interns highly, and is intent on interns developing their professional and academic skills. This genuine respect towards interns was present throughout my internship. At HAI, I was given an opportunity to manage and conduct a research project, and meet professionals in the field I am interested in. Another valuable asset to me, turned out to be my fellow interns, whom I could always turn to for advice on methodology, questions about literature, or when I just needed to vent about how long it takes to transcribe interviews. Being around such skilled and helpful peers enriched my overall experience.
Unmet contraceptive needs has historically had a negative affect on women’s reproductive health. Sub-Saharan Africa has one of the highest unmet contraceptive needs in the world, and Uganda has one of the region’s youngest populations. In the country, there are several barriers to access to contraceptives, which negatively affects users’ reproductive health and rights. This study sought to identify what the possibilities were for Ugandan users to access contraceptives, specifically in respect to possibilities to perceive unmet contraceptive needs, and possibilities to seek contraceptives. The results are expected to provide valuable information for further in-depth research on barriers to access to contraceptives, as well as inform Ugandan policy makers and intervention planners.
Twelve semi-structured phone interviews were conducted with key informants working with reproductive health in Uganda, to learn about their personal and professional experiences concerning access to contraceptives in the country. Collected data was coded using MAXQDA software, based on and adapted version of Levesque, Harris, and Russel’s framework for access to health services (2013). The coded data was analysed to identify barriers and facilitators to access to contraceptives.
Different barriers to access were identified in all four selected dimensions of access: limited approachability of contraceptive providers, low user perception of unmet contraceptive needs, limited acceptability of contraceptive use, and low user ability to seek contraceptives. Differences in user abilities were found to occur based on: living in urban or rural areas, education, gender, ethnicity, religious affiliation, and income. Additionally, limited availability of contraceptives, was a dimension of access which fell outside the scope of the adapted framework, which was discovered to be important in answering the main research question.