Knowledge, attitudes and strategies on contraceptive utilization among adolescents: views from beneficiaries and parents in City of Kigali (2024)

Introduction

Pregnancy among adolescents is a significant public health concern worldwide, particularly in developing countries, including Rwanda. Although contraception could be an effective tool to prevent unintended pregnancy, its utilization among adolescents is often low.

Aim

This study explored knowledge, attitudes and strategies on contraceptive utilization among adolescents.

Methods

Mixed method research (MMR) using a cross-sectional design, Sequential explanatory design was used to explore the views from 394 participants in Gitega Sector. This approach was chosen to first quantify the prevalence and patterns of contraceptive use through the questionnaire-based survey, and then to deepen understanding by exploring attitudes, beliefs, and experiences of adolescents and parents through in-depth interviews and focus group discussions. This sequential approach allowed quantitative findings to guide qualitative inquiry, providing richer context to the statistical data. For the quantitative phase, convenience sampling facilitated by the in charge of Health at the sector level and community health workers at the cell level ensured effective access to the study’s target demographic. Qualitative participants were purposively chosen to gain detailed insights from those identified with unique or significant experiences in the initial survey. Data were analyzed using SPSS version 25.0 for quantitative analysis and ATLAS.ti 23 for qualitative analysis.

Results

The study found that both adolescents and parents (59.1%) have a low level of knowledge about contraceptive utilization, with adolescents (75.5%) showing significantly lower knowledge than parents (46.4%). A majority of the participants, 195 (56.7%), had a positive attitude towards contraceptive utilization among adolescents. Bivariate analysis revealed significant associations between knowledge and socio-demographic factors such as education (P = 0.00) and marital status (P = 0.00), indicating higher knowledge levels among those with higher educational attainment and married individuals. Additionally, attitudes towards contraceptive utilization were significantly influenced by occupation (P = 0.005) and religion (P = 0.00). However, challenges such as the lack of parent-child communication and low knowledge contributed to the low contraceptive usage despite the existing initiatives such as the INGOBYI Activity.

Conclusion

The findings highlight a need for targeted interventions that address the specific challenges identified, including the lack of knowledge and communication barriers. Improved education and awareness programs for both adolescents and parents, along with supportive community strategies, may enhance contraceptive utilization. A concerted effort involving parents, healthcare providers, and community leaders may foster a supportive environment that encourages responsible and informed contraceptive use among adolescents.

Globally, adolescents account for 1.3billion individuals or 16% of the world’s population. Particularly concerning are the challenges associated with adolescent pregnancies, which threaten girls aged between 10 and 19 years [1]. In developing nations, 12million girls between 15 and 19 and at least 777,000 girls under 15 give birth annually [2]. These challenges are multifaceted, with physical, psychological, and social impacts. Physically, adolescent girls who become pregnant are at a higher risk of experiencing complications during pregnancy and childbirth [3], and their babies face a greater risk of preterm birth and low birth weights [4]. These girls are also more prone to mental health issues such as depression, anxiety, and stress [5]. Socially, they may suffer from stigmatization and isolation, while their education and future career prospects may be negatively affected [6,7,8].

While these challenges are profound, they are not insurmountable, and the key to overcoming them may lie in increasing contraceptive utilization among adolescents, particularly in low-income settings. However, there exists a critical gap in knowledge and utilization of contraceptives among adolescents in various countries. In Kenya, a study found that adolescents lack awareness of modern contraceptives such as levonorgestrel-releasing implant (Jadelle) and etonogestrel (Implanon), highlighting a significant knowledge gap [9]. In Nigeria, a contrasting picture emerges, where around 45.3% of unmarried sexually active adolescent girls used modern contraceptive methods in 2021 [10]. However, other studies from the region reported misconceptions among adolescents, such as beliefs that condoms do not make sex more enjoyable and that wearing them can cause infertility before delivering a child [9, 11, 12], these views further highlight the disparity in knowledge and attitudes about contraceptive utilization.

The parental attitudes and communication also play a vital role in shaping these perceptions. For example, a study in Nigeria found that parents had an unfavorable attitude against providing adolescents with contraceptives [13]. In contrast, a study conducted in Kenya revealed gender variations in parent-child communication and evidence that parents’ disapproval of romantic relationships during adolescence inhibited teenagers from reporting their relationship status [14]. Even when communication occurred, it was typically reactive, one-sided, and dictatorial, frequently initiated by parents [15].

Effective initiatives have been implemented to scale up contraceptive use among adolescents. For example, Zimbabwe’s sex education programs promote complete abstinence and contraception as preventative measures against teenage pregnancy [16]. However, these strategies have not been universally successful, leaving a gap in understanding the underlying knowledge and attitudes that inform contraceptive use among adolescents.

In Rwanda, teenage pregnancy has surged between 2017 and 2021, with adolescent mothers facing increased health risks such as eclampsia, puerperal endometritis, and systemic infections. Their children are also more susceptible to conditions like low birth weight and premature delivery. Recent studies conducted in Rwanda [17, 18] highlighted the low contraceptive utilization among adolescents, with a majority of respondents in one study revealing they didn’t use any contraceptives during their first sexual encounter [17].

According to the Rwanda Demographic Health Survey 2019–2020, 58% of married women utilize modern contraceptives, compared to 48% of sexually active single women [19]. This indicates a broader trend of increased contraceptive usage in Rwanda, with the percentage of women using modern methods rising from 17% in 2005 to 52% in 2010. Consequently, the average fertility rate in the country decreased from six to four births per woman during this period [19].

The City of Kigali, Rwanda’s capital, is uniquely positioned for the study of adolescent health issues due to its urban dynamics and diverse population. As Rwanda’s largest urban area, Kigali features prominent educational institutions, a blend of rural-urban migration, and a dynamic social landscape, all contributing to a more complex exposure to sexual and reproductive health information and services compared to rural areas. Additionally, Gitega Sector, located within Kigali, is noted for its high rates of teenage pregnancies, according to local health reports, making it an essential area for investigating the barriers to effective contraceptive use and the specific challenges that adolescents face in accessing reproductive health services.

The choice of Kigali for this study is driven by the urgent need to address the increasing issue of adolescent pregnancies and the gaps in contraceptive utilization within this demographic. The city’s dynamic setting enables a comprehensive analysis of urban-specific challenges and opportunities that can inform scalable and sustainable health interventions. By focusing on Kigali, the study aims to provide insights that are not only locally relevant but also applicable to other urban settings in Sub-Saharan Africa with similar socio-economic dynamics.

This research therefore, aims to bridge this knowledge gap and seeks to inform policy and initiatives to improve adolescent health outcomes. A cross-sectional design used a mixed method approach was applied to explore the knowledge, attitude and strategies on contraceptive utilization among adolescent girls and parents in Kigali city.

Study area

This study was conducted in Gitega sector, this is a territorial administrative entity within Nyarugenge District, City of Kigali (CoK), in Rwanda coordinated on: Latitude 1° 57’ 17” South and Longitude 30° 3’ 24” East. It is located within the medicalized area of RWAMPARA Health Center. According to data from the health center, contraceptive utilization, including both natural and modern methods, is 37.1% in this sector. As per the Rwanda population and housing census 2012, Gitega has total population of 28,870, with 15,069 males and 13,801 females. Adolescents (aged 10–19) account for 5,898 of the population in Gitega sector. Among the population 12,768 (59.9%) are single, 7,250 (34%) are married, and 1,311 (6.1%) are separated.

Study design and approach, sample size and sampling strategy

A cross-sectional design was employed in this study, utilizing a mixed method approach. The sample size was determined using the Yamane formula, with a 95% confidence level and a five-percentage-point margin of error, resulting in a total of 394 participants of the study. The 344 participants were used in quantitative approach and 50 participants were used for the qualitative approach as follows: Five focus group discussions (FGDs) with 40 participants, divided into groups of either parents or adolescents to promote open dialogue and minimize power dynamics that could potentially influence the discussions. Specifically, we included 24 parents and 16 adolescents across these groups, aiming to facilitate candid discussions about personal and sensitive topics like contraceptive use. Additionally, to enrich our qualitative data and explore more complex or nuanced attitudes that might not emerge in a group setting, we conducted in-depth interviews with 10 participants, comprising 5 parents and 5 adolescents. These interviews allowed for a more intimate exploration of individual experiences and perceptions, providing a detailed layer of qualitative data that complements the insights gained from the focus groups. In our study, we utilized non-probability sampling methods to effectively engage with the community and gather diverse insights. Convenience sampling was employed for the quantitative component, facilitated by the sector-level Health Officer and community health workers, chosen for its practicality in accessing a broad demographic within the Gitega community. For the qualitative component, which included focus group discussions and in-depth interviews, we opted for purposive sampling. All study participants were aged 18 and above, eliminating the need for parental assent. However, procedures were in place to secure such assent if underage participants had been included.

Study population

The target population for our study was carefully selected from the Gitega sector and comprised both adolescents and a diverse group of parents, including mothers, fathers, guardians, and adolescent mothers, all within the reproductive age range of 15 to 49 years. This selection strategy resulted in a total of 151 adolescents and 193 parents participating in the quantitative approach as well as 29 parents and 21 adolescents in the qualitative approach. Our inclusive approach ensured that we captured a wide range of perspectives on contraceptive utilization. To further enrich the discussions and enhance the relevance of our findings, we specifically included parents and guardians who have raised or are currently raising at least one adolescent. When selecting these participants, we not only verified the presence of an adolescent child but also considered the number of adolescents each individual has raised. This was done to explore how different levels of parenting experience might influence participants’ attitudes and practices regarding contraceptive use. Importantly, while we recognized the potential influence of parity, our primary focus remained on direct experiences related to the upbringing of adolescents and discussions on their contraceptive use.

Data collection instrument

A semi-structured questionnaire was developed using Kobo Collect to carry out quantitative data collection. The questionnaire was initially created in English and then translated into the local language, Kinyarwanda, to accommodate community members who might have challenges with the English language. The questionnaire consisted of questions and sub-questions drawn from previous studies (17,18) on contraceptive utilization among adolescents. In addition to the questionnaire, the researchers developed an in-depth interview guide and a focus group discussion guide to collect qualitative data.

Data collection procedure

Data were collected by a team of 20 trained collectors who underwent a three-day training focusing on ethical considerations, data collection techniques, and the sensitive nature of the study topics. Interviews were designed to last between 20 and 30min to maintain depth and participant comfort. After receiving authorization from the City of Kigali, local leaders were informed about the study. They then facilitated the researchers in collecting data from Rwampara Health Center, Kigali Leading TVET School, and the Gitega community. Ethical clearance for the study was secured from the institutional review board of the University of Rwanda, College of Medicine and Health Sciences with (Ref: CMHS/IRB/OO2/2023).

Data analysis

Collected data were processed using Excel and imported into SPSS version 25.0 for analysis. The results were presented in tables and figures. For the quantitative data analysis, descriptive statistics, including frequencies, percentages, and means, were generated using SPSS 25.0. After the qualitative data collection with In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs), the transcription of audio-recorded data was done. These transcriptions were then translated as necessary. Using ATLAS.ti 23, the research team engaged in qualitative data coding, where codes were carefully developed and applied to segments of text to categorize and organize the data. This coding facilitated the extraction of key themes through a methodical thematic analysis, enabling a deeper understanding of the textual data and ensuring the findings were grounded in the empirical evidence collected.

The data were collected using a combined quantitative-qualitative approach: The socio-demographic characteristics and contraceptive utilization among adolescents in Kigali, Rwanda, presented in Table1, reveal several important findings. Predominantly, the adolescents surveyed possess a secondary education, as indicated by 58.8% of participants in the quantitative approach. Most of the adolescents are single, comprising 55.7% of the sample in the quantitative survey. Economically, the majority are classified as resourceful poor (Category 3), making up 71.3% of the quantitative sample.

Adolescence, a crucial stage in development, brings forth various challenges, especially in the area of sexual and reproductive health. Understanding the dynamics of contraceptive knowledge, attitudes, and utilization among adolescents is pivotal for public health initiatives. This quantitative study conducted in Kigali city aims to delve into these intricacies, exploring topics such as the prevalence of contraceptive awareness, factors hindering usage, attitudes towards contraceptive use, and existing strategies to mitigate teenage pregnancies. The ensuing sections detail the findings, revealing the multifaceted influences shaping contraceptive practices among the youth in this community.

Knowledge regarding contraceptive methods

The majority of respondents, 288 (83.5%), self-reported to know at least one contraceptive method. To determine the level of knowledge on contraceptive utilization, 11 variables were computed together and scored 11 points in total. The overall results showed a low level of knowledge among adolescents and parents (59.1%), with adolescents (75.5%) having lower knowledge compared to parents (46.4%). The availability of seminars, clubs to empower adolescents, and health education attendance were positively associated with the level of knowledge (P < 0.05). The results showed that the condom 86 (30%) is the most commonly known contraceptive method, while the implant (9%) is the least known as presented in Fig.1.

Factors contributing to adolescents’ low contraceptive use

The study explored several facets that contribute to low contraceptive use among adolescents, including religious influence, autonomy in relationships, perception of harm, and communication patterns.

Concerning religious influence, respondents were queried about exposure to religious teachings concerning contraceptives. Of those who heard pastors, priests, or Imams preaching on this subject, 74 (21.6%) agreed that the intent was to sensitize people about contraceptive use, while 115 (33.4%) disagreed. Statistical analysis revealed a positive association between harmfulness perceptions of contraceptives, parental consent to adolescents for contraceptive use, and the purpose of preaching about contraceptive use with religious beliefs (P-value < 0.05) as shown in Table2 below.

In the realm of autonomy in relationships, a significant majority, 255 (74.1%), agreed that females could decide on the type of contraceptive method within relationships, while 71 (20.6%) disagreed. Additionally, the study found that 214 (62.4%) disagreed with the notion that only married couples should use contraceptives.

With regard to communication about contraceptives, most respondents, 240 (70%), confirmed discussing contraceptives with someone, but only 134 (38.8%) said they discussed it with parents or an elder person. A plurality, 135 (39.1%), mentioned that they discuss contraceptives with peers, while others do not engage in such conversations or preferred not to disclose.

Finally, the data indicated mixed perceptions of harm concerning contraceptive use among adolescents. A notable number of respondents, 167 (48.4%), considered contraceptives not harmful, but 128 (37.1%) deemed them harmful, and 50 (14.5%) were unaware of their harmfulness.

Attitudes towards contraceptive utilization among adolescents

The study also examined attitudes towards contraceptive utilization among adolescents, exploring participants’ perspectives on parental consent and perceived effects on young users. In our study, attitudes towards contraceptive utilization were quantified using a Likert scale, with scores ranging from 0 to 100. We classified scores of 60 or above as indicative of a positive attitude, and scores below 60 as indicative of a negative attitude. This cutoff was selected based on the distribution of scores within our sample, where a score of 60 represented the upper third percentile, reflecting a statistically significant favorable disposition towards contraceptive use. This threshold helps ensure that the classification of attitudes is both statistically and contextually grounded in the observed data patterns. Regarding attitudes, the majority of participants, 195 (56.7%), expressed a positive attitude towards contraceptive utilization among adolescents, while 148 (43.0%) displayed a negative attitude.

The matter of parental consent was nuanced, with participants divided on whether parents can or should agree to consent their adolescents to contraceptive use. Specifically, 137 (39.7%) respondents believed that parents can consent, 136 (39.4%) thought that parents should disagree with consenting, and 72 (20.9%) indicated that such consent depends on the level of parent-adolescent communication.

The study further revealed mixed views on how adolescents are affected by contraceptives compared to adult women. A majority, 181 (52.6%), opined that adolescents are more affected by contraceptives, while 89 (25.9%) felt that adolescents could use some methods without undue risk.

Strategies in place to cope with teenage pregnancies

The study also investigated strategies in place within communities to cope with teenage pregnancies and to enhance awareness of contraceptive utilization.

A noticeable portion of respondents, 127 (36.9%), reported the availability of regular seminars or meetings aimed at sensitizing adolescents about the prevention of teenage pregnancies in their community as shown in Fig.2.

Furthermore, a significant majority, 234 (67.8%), stated that programs designed to encourage parents to communicate openly with their children about sexual and reproductive health were available in their community. Conversely, 25 (7.2%) indicated that no such programs were accessible, while 86 (24.9%) were unaware of the existence of any programs.

Lastly, the study explored the availability of contraceptive services through community health workers. While a few respondents, 74 (21.5%), asserted that community health workers did not offer contraception services, a majority, 213 (61.9%), confirmed their provision of such services. Meanwhile, 57 (16.6%) participants lacked information on the matter.

The bivariate analysis of socio-demographic factors influencing knowledge, attitudes, and strategies towards contraceptive utilization among adolescents and their parents reveals significant variances based on gender, education, marital status, occupation, Ubudehe category, and religion. Gender does not significantly influence knowledge (P = 0.66) or attitudes (P = 0.97), with both males and females showing similar patterns. However, education level is a strong determinant, with higher education correlating with higher knowledge (P = 0.00) and varied attitudes. For instance, individuals with a Master’s degree or above show the highest knowledge (88.9%) and positive attitudes (77.8%). Marital status also impacts knowledge (P = 0.00), with married individuals exhibiting higher knowledge (51.5%) compared to single (30.9%) and divorced individuals (75%). Occupation significantly affects both knowledge (P = 0.00) and attitudes (P = 0.005), with employed individuals having higher knowledge (55.5%) and students showing the lowest positive attitudes (40.5%). Ubudehe category indicates significant disparities in both knowledge and attitudes (P = 0.00 for both), with lower categories showing lower knowledge and higher positive attitudes. Religion also shows significant differences, with Christians having the highest knowledge (47.1%) and positive attitudes (56.3%) compared to Muslims and Traditionalists (Table 3).

This phase of the study delves into the diverse perceptions and attitudes surrounding contraceptive utilization among adolescents in Kigali city. Conducted on February 2–3, 2023, participants shared their insights on various aspects of contraceptive usage, including awareness of different methods, cultural and religious influences, parental attitudes, and existing initiatives aimed at preventing teenage pregnancies. The qualitative data were meticulously processed and analyzed using ATLAS.ti.

A detailed document summary report, generated on February 20, 2023, includes all interviews and focus group discussions, featuring quotations and associated codes. This report meticulously outlines the frequency and density of each code, providing a structured overview of the thematic ground covered.

Furthermore, an Excel export of these initial codes, detailing their ground and density, was prepared to demonstrate the quantitative representation of thematic occurrences, ensuring the analysis process is transparent and replicable. The segmentation of qualitative data codes, exported directly from ATLAS.ti, reflects the complex interplay between societal norms, individual beliefs, and practical considerations that influence contraceptive use among Gitega’s youth.

The findings represent a comprehensive understanding of the multifaceted factors that contribute to or hinder contraceptive use among the youth in this Gitega sector, reflecting a complex interplay between societal norms, individual beliefs, and practical considerations (Table 4).

Knowledge regarding contraceptive methods

During IDIs and FGDs, the majority of participants reported having knowledge of at least one contraceptive method, with the condom being the most commonly known. Some examples of contraceptive methods were reflected on by participants during qualitative interviews:

It is safe to use a condom because it prevents pregnancy as well as sexually transmitted diseases such as AIDS, gonorrhea, and others. - IDI participant.

She might know how to count her days or she uses pills or injections and a condom. In addition, there are two types of IUDs; some IUDs are inserted in the uterus for 12 years or 2 years. Again, implants are put in the hand or other parts of the body for 2 or 5 years. - IDI participant.

Some initiatives were reported to raise awareness on contraceptive utilization among adolescents and prevent teenage pregnancies:

There are sessions that are organized, and they train the youth when there is a meeting; there are schools where children learn it as part of their studies and put condoms in places where people meet. Non-governmental organizations are also involved in different programs like INGOBYI activity. - IDI Participant.

There is an initiative to welcome students on holidays in order to advise them on how to prevent unintended pregnancies. It is usually done at the Maison de Jeune KIMISAGARA. - FGD participant.

Factors contributing to adolescents’ low contraceptive use

Different questions were asked to explore factors associated with low contraceptive utilization among adolescents:

Religious influence

“Religions do not allow people who are not yet married to have sex because it is considered a sin, so I think no religion can teach adolescents to use contraceptives. And another thing is that there are religions that do not accept contraceptive use because they say that it is killing children and God’s promise is to give birth and fill the world.” - FGD participant.

Cultural Perception:“In Rwandan culture, elders used to give birth to many children, and they did not use contraceptives because they even didn’t exist; I feel that culture has no role in it.” - IDI participant.

Choice and Side Effects:“Everyone has his/her choices, but adolescents can probably use contraceptives. There are many methods adolescents can use which cannot affect their lives, such as using condoms or taking pills after unprotected sex. So, adolescents can experience the same contraceptive side effects as adult women.” - IDI participant.

Attitudes towards contraceptive utilization among adolescents

The results indicated that the majority of respondents are not sure whether parents can consent to adolescent contraceptive utilization.

Concerning parental consent

“There are some parents who can allow their children to use contraceptives, there are those who cannot, and there are those who are really ashamed to tell their children about contraceptive utilization to prevent unintended pregnancies.” - FGD participant.

Concerning employment of parents

“It is rare to find a parent discussing contraceptive use with his/her child because here in Kigali the parents are busy working, and I think that this is among the reasons why adultery is increasing.”-FGD participant.

Regarding adolescents’ needs

“As long as teenagers and young adults tend to be more sexually active than adults. So I understand, they are the ones who should use it because they are the ones who have the most value.” - IDI Participant.

Strategies in place to cope with teenage pregnancies

Upon asking participants about initiatives available to cope with teenage pregnancies, some initiatives were reflected on qualitatively:

The program I know is called Dreams program. It is a project that helps girls where they meet once a week at the sector office and teach them how to avoid unplanned pregnancies and how to use birth control methods if they are going to have sex. They choose children aged 10 to 18 and those who dropped out of school. - FGD participant.

Non-governmental organizations are also involved in different programs like where INGOBYI activity organizes and trains the youth about sexual reproductive health and rights. - IDI participant.

“I think that the information comes from community health workers because they usually live in the community and they know the cases of children who are in need of contraceptives and those who are dealing with unintended pregnancies.” - FGD participant. Most of them said that community health workers are the best ones to offer contraceptive services because they are closer to them.

“There are shops on the street, and when you attain majority age, you go and give your ID card, and they give you condoms.” - FGD participant. The large number of respondents, 213(61.9%), knew where to get contraceptives in their community apart from community health workers.

The aim of this study was to gain insights into knowledge, attitudes, and strategies regarding contraceptive use among adolescents in Gitega sector, City of Kigali. We compared our findings with related studies from different regions for a comprehensive understanding. Our study’s quantitative results demonstrate a significant proportion of respondents are aware of at least one contraceptive method, mirroring similar studies in Kenya [9]. However, there exists a notable gap between high awareness and low comprehension among adolescents (75.5%) and parents (46.4%) [20]. This discrepancy not only signals a critical gap between superficial awareness and actionable understanding but also illuminates the need for comprehensive, nuanced education initiatives, not merely widespread awareness campaigns. These insights are further elucidated through qualitative insights which reveal that while many participants are aware of contraceptives, their knowledge does not translate into understanding proper usage and suitability for different individuals [12, 21]. The need for educational initiatives like INGOBYI and school sessions is highlighted, moving beyond mere awareness to provide comprehensive, nuanced education that addresses these misconceptions.

Regarding factors contributing to low contraceptive use among adolescents, our quantitative data indicates a lack of dialogue about contraceptives between adolescents and parents or elders, akin to observations from Ghana [22], and shows a significant rise in contraceptive use with age, supporting research by Lawrence and Philbin [23]. Qualitative findings add depth to this picture, showing the influence of religious beliefs where contraceptives are often viewed as sinful or against divine commands, discouraging use among adolescents [24]. Furthermore, the historical context and prevailing cultural norms in Rwanda may conflict with the adoption of modern contraceptive methods [25], necessitating tailored interventions that address both communication barriers and the cultural and religious contexts that shape contraceptive use.

In exploring attitudes and cultural perceptions towards contraceptive utilization, quantitative analysis reveals that, unlike findings in Uganda [26], a majority of respondents in Rwanda (66.1%) do not view contraceptive use as contrary to their culture. Yet, many still harbor fears and misconceptions, with 52.6% believing that adolescents are negatively affected by contraceptives, a sentiment also observed in Guinea Conakry [15]. Qualitatively, discussions about cultural norms and the historical context in Rwanda suggest a complex relationship between traditional values and modern contraceptive methods [25], calling for context-specific interventions to navigate and reconcile these cultural sensitivities.

The value of community programs in fostering communication about sexual and reproductive health (SRH) between parents and children is recognized in both quantitative and qualitative findings [27]. Nonetheless, persistent questions about the effectiveness and reach of these interventions suggest a gap between program objectives and outcomes, emphasizing the need for a thorough evaluation of existing programs to ensure they meet the community’s needs effectively. This includes assessing strategies that address both accessibility and the practical application of contraceptive education and services. Additionally, informal methods like street shops for contraceptive distribution are noted, which highlight gaps in accessibility and effectiveness and necessitate comprehensive evaluations to strengthen these initiatives.

Finally, our study identifies various community and institutional initiatives aimed at coping with teenage pregnancies, such as the Dreams program and the engagement of community health workers. While these strategies showcase an active community response, they also hint at potential gaps in accessibility and effectiveness. The qualitative findings depict a multifaceted picture of attitudes toward adolescent contraceptive use, underscoring the need for strategies that create safe spaces for dialogue between parents, adolescents, and community members. These strategies should aim to break down stigmas and facilitate open discussions [28], ensuring collaborative decision-making around contraceptive use and bolstering a supportive network for adolescents’ sexual and reproductive health.

Strengths and limitations

Strengths

Engagement with adolescents

Recognizing that adolescents encountered difficulties in discussing contraceptive utilization, skilled youth facilitators created a safe and non-judgmental space. They engaged adolescents in interactive discussions, helping them overcome fears that knowledge of contraceptives might label them as involved in adultery.

Local support

The study received backing from local authorities and secondary school administrations in Gitega sector. Their support and briefing about the study’s significance motivated participants to provide accurate and reliable information.

Mixed method approach

Utilizing a cross-sectional design with both quantitative and qualitative data allowed for a more comprehensive understanding of the subject. The use of Kobo Collect for data collection in the local language, Kinyarwanda, helped reach a wider demographic.

Collaboration with community leaders

After receiving authorization from the City of Kigali, researchers worked with local leaders to collect data from key institutions such as Rwampara Health Center and Kigali Leading TVET School.

Limitations

Cultural sensitivity

Open discussions about contraceptives were initially hindered by cultural perceptions and fears among the adolescents. Although the facilitators managed to overcome this to an extent, some reservations might have persisted.

Geographical limitation

The study was confined to Gitega sector in City of Kigali, Rwanda. While providing valuable insights into this area (where contraceptive utilization is 37.1%), the findings may not be universally applicable.

Design and sampling technique limitations

The use of a cross-sectional design in this study, combined with convenience sampling, introduces inherent limitations. Firstly, the cross-sectional nature of the study restricts our ability to infer causality between observed attitudes towards contraceptive use and the factors influencing these attitudes. This is because temporal relationships cannot be established. Secondly, convenience sampling, while practical, may not provide a fully representative sample of the broader population. This can lead to potential biases, including the social desirability bias, which might result in an overestimation of positive attitudes and proactive behaviors concerning the provision of contraceptive services to adolescents. Future studies might consider using longitudinal designs and probabilistic sampling methods to overcome these limitations and provide a more robust understanding of the causal relationships and the generalizability of the findings.

ATLAS.ti:

Archive for Technology, Lifeworld and Everyday Language

CMHS:

College of Medicine and Health Sciences

FGD:

Focus Group Discussion

IDI:

In-depth Interviews

IRB:

Institution Review Board

IUD:

Intra-Uterine Device

SPSS:

Statistical Product and Service Solution

SRHR:

Sexual Reproductive Health and Rights

TFR:

Total Fertility Rate

Authors and Affiliations

1. College of Medicine and Health Sciences, School of Public Health, Department of Environmental Health Sciences, University of Rwanda, Kigali, Rwanda

   Jean Baptiste Hategekimana,Adolphe Ndikubwimana,Justin Ndayisenga,Fidele Niyitegeka,Daniel Ukwishatse,Serieux Cyubahiro,Bivegete Kenny Ntwali,Noel Korukire,Felix K. Rubuga,Patrick Karakwende,Celestin Banamwana,Pierre Dukuziyaturemye,Jean Muhire&Theoneste Ntakirutimana

2. College of Medicine and Health Sciences, School of Nursing and Midwifery, Department of General Nursing, University of Rwanda, Kigali, Rwanda

   Absolomon Gashaija,Alice Nyirazigama&Marie Josee Mwiseneza

3. Faculty of Pharmacy, University of Lagos, Lagos, Nigeria

   Deborah Oluwaseun Shomuyiwa

4. Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

   Don Eliseo Lucero-Prisno III

5. Center for Impact, Innovation and Capacity building for Health Information systems and Nutrition (CIIC-HIN), Kigali, Rwanda

   Absolomon Gashaija&Felix K. Rubuga

Contributions

JBH, JN, FN, DU, SC, BKN, AG, AN, NK, FRK, PK, CB, PD, JM, MJM, TN, AN, DOS and DELP played a significant role in the conception, design, data analysis and interpretation, and writing of the manuscript of the study. All authors read and approved the manuscript.

Corresponding author

Correspondence to Jean Baptiste Hategekimana.

Ethics approval and consent to participate

For this research to be conducted, Ethical clearance was obtained from Institution Review Board (IRB) of UR/CMHS (Ref: CMHS/IRB/OO2/2023). The Ethical Clearance submitted to City of Kigali to obtain authorization for data collection in Nyarugenge District, Gitega sector. The researchers gave clear explanations to the participants regarding the study including the main objective beforehand of data collection. The participants were informed that it was voluntary participation. Confidentiality of participants was ensured by giving identification codes instead of names. Participants who accepted to participate voluntarily, were given consent form to sign and were interviewed face to face.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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