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Background To meet the needs of female adolescents from low-income urban areas for sexual and reproductive health (SRH) care, vouchers providing free-of-charge access to SRH care at 19 primary care clinics were distributed in Managua, Nicaragua. These vouchers substantially increased the use of services, demonstrating that many adolescents are willing to use such services, if readily accessible. The voucher redemption made it possible to identify the nature of existing, but largely unmet, needs for SRH care.
Method The medical files from 3301 consultations with female adolescents were analysed using descriptive statistical methods and multiple logistic regression.
Results Female adolescents presented SRH problems that merited medical attention. The mean number of problems presented was 1.5 per consultation: 34% of the vouchers were used for contraceptives, 31% for complaints related to sexually transmitted infection (STI) or reproductive tract infection (RTI), 28% for advice/counselling, 28% for antenatal check-up and 18% for pregnancy testing. A new category of health care users emerged: sexually active girls who were neither pregnant nor mothers and who sought contraceptives or STI/RTI treatment. Contraceptive use doubled among the sexually active non-pregnant voucher redeemers. Consultation with a female doctor younger than 36 years was associated with a higher chance of having contraceptives prescribed.
Conclusion Accessible and appropriate SRH care has the potential to make an important contribution to the increased contraceptive use, decreased risk of unwanted teenage pregnancies and decreased prevalence of STIs/RTIs among underserved adolescents. Once adolescents access the services, providers have a crucial role in ensuring current and continuing needs are met.
Données de base Afin de répondre aux besoins des adolescentes dans les zones urbaines paubres pour les soins de santé sexuelle et reproductive (SSSR), des bons donnant droit à l'accès gratuit aux soins de santé reproductive dans 19 cliniques de santé primaire ont été distribués à Managua au Nicaragua. Ces bons ont substantiellement accru l'usage de ces services, démontrant ainsi que beaucoup d'adolescentes étaient disposées à utiliser ces services s'ils étaient plus accessibles. Le système des bons pour soins gratuits a permis d'identifier la nature des besoins existants mais non assurés pour les SSSR.
Méthode Les dossiers médicaux de 3301 consultations d'adolescentes ont été analysés en utilisant des méthodes statistiques descriptives et des régressions logistiques multiples.
Résultats Les adolescentes présentaient des problèmes SSSR méritant une attention médicale. La fréquence moyenne des problèmes était de 1,5 par consultation: 34% des bons ont été utilisés pour des contraceptifs, 31% pour des infections sexuellement transmissibles (IST) ou des infections du tractus reproducteur (ITR), 28% pour des consultations/conseils, 28% pour des contrôles anténataux et 18% pour des tests de grossesse. Une nouvelle catégorie d'utilisatrices des soins de santé a ainsi émergé: celle de filles sexuellement actives, n’étant ni enceintes ni mères, à la recherche de contraceptifs ou de traitement pour des IST/ITR. L'usage de contraceptifs a doublé chez celles sexuellement actives, non enceintes qui ont fait usage des bons gratuits. La consultation menée par un médecin féminin de moins de 36 ans était associée avec une chance plus élevée de voir prescrire un contraceptif.
Conclusion Des SSSR appropriés et accessibles peuvent contribuer de façon importante à l'augmentation de l'utilisation de contraceptifs, à la réduction du nombre de grossesses indésirées et à la réduction de la prévalence des IST/ITR chez les adolescentes les moins prises en charge. Lorsque les adolescentes ont accès aux services, le rôle crucial des agents de la santé est de veiller à ce que les besoins actuels et continus soient assurés.
Antecedentes Con el fin de responder a las necesidades de atención en salud sexual reproductiva (SSR) de mujeres adolescentes, provenientes de áreas urbanas de povres, se distribuyeron bono para recibir atención gratis en SSR en 19 centros de atención primaria en Managua, Nicaragua. Estos bonos aumentaron sustancialmente el uso de los servicios, demostrando que muchas adolescentes están dispuestas a utilizarlos si son asequibles. El reembolso de los bonos hizo posible que se identificaran las necesidades existentes, y en gran parte no solventadas, de atención y cuidados en SSR.
Método Se analizaron las historias clínicas de 3301 de mujeres adolescentes que asistieron a la consulta de SSR utilizando métodos estadísticos descriptivos y regresión logística múltiple.
Resultados Las adolescentes presentaban problemas de SSR que requerían atención médica. La media era de 1.5 problemas por consulta: 34% de los cupones se utilizaron para obtener anticonceptivos, 31% por quejas relacionadas con infecciones de transmisión sexual (ITS) o infecciones del tracto reproductivo (ITR), 28% para pedir consejo, 28% para control antenatal y 18% para prueba de embarazo. Emergió una nueva categoría de usuario de atención sanitaria: jóvenes sexualmente activas que no son ni madres ni están embarazadas, que buscan métodos anticonceptivos o tratamiento para ITS/ITR. El uso de anticonceptivos se dobló entre las jóvenes sexualmente activas no embarazadas. El ser atendido por una doctora menor de 36 años estaba asociado con una mayor probabilidad de recibir una prescripción de anticonceptivos.
Conclusión Una atención en SSR asequible y apropiada tiene el potencial de contribuir de forma importante a aumentar el uso de anticonceptivos y disminuir tanto el riesgo de embarazos no deseados entre adolescentes como la prevalencia de ITS/ITR entre las mismas. Una vez que las adolescentes han accedido a los servicios, los proveedores tienen un papel crucial en asegurar que sus necesidades actuales y futuras son satisfechas.
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Nicaragua has one of the highest adolescent fertility rates in Latin America, with 119 births annually per 1000 young women aged 15–19. High fertility rates are associated with low socioeconomic status and low educational attainment (INEC Instituto Nacional de Estadística y Censos & Ministerio de Salud 2001). In addition, adolescents experience high rates of unwanted pregnancy, illegal abortions and maternal mortality and are at high risk of contracting sexually transmitted infections (STIs), including HIV. As the use of contraceptives and condoms could diminish these risks, only 7% of sexually active female adolescents use a condom and only 47% use another modern method of contraception (INEC Instituto Nacional de Estadística y Censos & Ministerio de Salud 2001).
An important reason for the low use of contraceptives is that adolescents have limited access to contraceptives and counselling in Nicaragua (Braddock et al. 1995; Zelaya et al. 1996; Berglund et al. 1997). Although wide agreement exists that health care services should respond to these needs – as explicitly outlined in the Ministry of Health guidelines (Direccion General de Servicios de Salud & Direccion de atencion integral a la mujer 1999) – there are numerous obstacles to accessing appropriate care. To address this situation, the Central American Health Institute (ICAS) piloted a competitive1 voucher programme aimed at increasing both the accessibility and quality of sexual and reproductive health (SRH) care for poor adolescents (Meuwissen et al. 2006a,b,c,d). The pilot programme was implemented in collaboration with the London School of Hygiene and Tropical Medicine, and financed by the British Department for International Development.
Conventional estimates of unmet needs for health care or contraceptives are based on interviews with women. However, a disadvantage of this approach is that the extent to which unmet needs could be met by the increased access to appropriate health care services remains unknown. The intervention described in this article succeeded in mobilizing adolescents from disadvantaged areas from Managua to attend health services. Evaluation showed that the use of SRH care among female adolescents increased considerably (adjusted odds ratio 3.1, 95% confidence interval 2.5–3.9) (Meuwissen et al. 2006c). As such, the intervention provides unique data to answer the question: What are the health care problems for which female adolescents consult a doctor if he/she is available, accessible and affordable? The information collected allows this question to be explored, taking into account the different characteristics of the girls (demographic, socioeconomic, knowledge and experience with contraceptives) and of the providers, as well as the factors associated with demand for contraceptives in sexually active teenagers. These results provide valuable input to the discussion of the public health relevance of interventions that aim to increase the access and quality of SRH care for underserved adolescents – a phenomenon common to many developing countries.
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In total, 3067 girls used 3301 vouchers [190 girls (6%) used more than one voucher for various episodes of ‘illness’]. Forty per cent of the girls came back for a follow-up visit. Most vouchers were redeemed in NGO clinics (2063, 62.5%), against 733 (22%) in private clinics and 505 (15%) in public clinics. Most girls (59%) were having a consultation with a young female doctor (aged less than 36). Twenty-two girls were more than 20 years old and were excluded from further analysis.
Records were generally well kept and most questions completed. Common medical questions had few missing values, while questions about former health care use or provider of contraceptives had not been answered on about 15% of forms.
Who uses the services?
In Table 1, an overview is given of the main characteristics of the girls who used their voucher. Nearly half of the girls who used the services were younger than 18 years. Only 21% of the girls were earning an income, 43.5% were studying and 42% stayed at home. Nearly all (86%) were sexually active and 28% were pregnant. Thirty-five per cent of the girls were already mothers (78% with one child, 19% with two and 3% with three or more, not shown in Table 1). Seven girls had given birth to twins and 63 girls reported that a child had passed away (not shown in Table 1).
Table 1. Characteristics of the girls on their first visit with voucher and relation between characteristics and the use of services in the last year (N = 2551)
|Variables||Categories||All N (%)||Use of SRH care† last year||LRT§P|
|% used||Adjusted odds ratio‡ (95% CI)|
|Age group||11–15 years||501 (16.5)||12.4||1.0|| |
|16–17 years||968 (31.8)||25.8||1.1 (0.8–1.6)|| |
|18–20 years||1576 (51.8)||36.6||1.2 (0.9–1.8)|| |
|Level of school attainment M = 1||0–6 years||922 (30.3)||31.5||1.0|| |
|7–9 years||1310 (43.0)||29.7||1.0 (0.8–1.3)|| |
|> 10 years||812 (26.7)||25.6||0.8 (0.6–1.0)|| |
|Daily activity||Studying||1138 (37.4)||20.3||1.0||0.02|
|Working||446 (14.7)||37.5||0.9 (0.6–1.2)|
|Working and studying||186 (6.1)||34.2||1.4 (0.9–2.1)|
|At home||1275 (41.9)||33.9||0.7 (0.6–1.0)|
|Status of relationship||Single||1185 (38.9)||14.7||1.0||< 0.001|
|Engaged||1425 (46.8)||37.6||1.7 (1.4–2.2)|
|Married||435 (14.3)||40.5||1.9 (1.4–2.7)|
|Category of childbearing||Not yet had intercourse||431 (14.2)||1.4||1.0||< 0.001|
|Sexually active (not pregnant/ mother)||923 (30.3)||25.0||17.7 (7.1–44.5)|
|First time pregnant||626 (20.6)||15.3||9.2 (3.6–23.8)|
|Mother and pregnant||232 (7.6)||40.6||32.1 (12.1–85.2)|
|Mother not pregnant||833 (27.4)||56.6||62.1 (24.2–159.3)|
|Refrigerator M = 13||Not present||1759 (58.0)||30.3||1.0|| |
|Present||1273 (42.0)||27.5||1.0 (0.8–1.2)|| |
|No of people/bedroom M = 26||0–2||1376 (45.6)||28.7||1.0|| |
|> 2–3||958 (31.7)||30.2||1.0 (0.8–1.2)|| |
|> 3+||685 (22.7)||28.4||1.0 (0.8–1.3)|| |
|Total|| ||3045 (100)||29.1|| || |
The percentages using SRH care in the year before the voucher visit are shown in column 2 of Table 1. Less than 30% of the girls reported use of SRH services in the last year. When all factors were considered simultaneously through logistic regression analysis, single girls and girls staying at home had made significantly less use of health services, whereas girls who were already mothers had made most frequent use. The profile of the girls using the vouchers was different. The vouchers succeeded in attracting different types of users to the clinics: 45% were neither pregnant nor mothers and 39% were single (Table 1).
What are the reasons for consulting a doctor?
In total, 5069 reasons for consultation were registered, on average 1.5 reasons per consultation. One third of the vouchers were used for contraceptives (34%), nearly one third (31%) for complaints related to an STI or RTI, 28% for advice/counselling, 28% for antenatal check-ups and 18% for pregnancy testing. In 10% of the consultations, vouchers were used exclusively for advice/counselling. In 50% of the consultations provided to sexually active girls who were neither pregnant nor mothers, contraceptives were requested and 39% of these girls presented with complaints of symptoms of either an STI or an RTI. Many had additional requests for advice or counselling (Table 2).
Table 2. Reasons for using a voucher, for all medical consultations provided to girls and distributed over each childbearing category
|Problems identified||All N = 3301 (100%)||Reason for consultation in % per childbearing category†|
| Not started‡ 441 (100%)|| Started‡ 1001 (100%)||First pregnancy 673 (100%)||Pregnant and mother 249 (100%)||Mother not pregnant 937 (100%)|
|Advice/counselling|| 923 (28.0)||73.2||28.7||11.7||10.4||22.2|
|Pregnancy test|| 581 (17.6)||0.0||25.4||22.9||24.9||11.8|
|Antenatal care|| 922 (27.9)||0.0||0.0||100||100||0.0|
|Other reproductive health issues|| 347 (10.5)||22.7||11.5||3.6||1.6||11.1|
|Other health issues (gastritis, dermatitis, etc.)|| 136 (4.1)||14.7||3.6||0.4||0.8||3.2|
|Total reasons for consultations||5069||552||1585||1071||418||1443|
|Mean number of reasons per consultation|| 1.5||1.3||1.6||1.6||1.7||1.5|
Of 1137 consultations for contraceptives, only 39% were used exclusively for this reason; in 27% also advice/counselling was provided; 13% a pregnancy test (of which some were positive); 28% STI/RTI treatment and 8% advice on other complaints (not shown).
Some girls discussed problems related to sexual abuse with the doctor, and others referred to previous abuse when asked for the age at first intercourse. Forty-two (2%) girls had had intercourse before their first menstruation, some as young as 8 years and 146 (6%) in the year of their first menstruation.
What is their knowledge of, experience with and demand for contraceptives?
In Table 3, details are tabulated on voucher users’ knowledge of, experience with and demand for contraceptive methods according to the category of childbearing experience. Some interesting findings surface
Table 3. Knowledge, past and present use of contraceptives, for all girls and for each childbearing category
|Categories||All 3045‡ (100)||Started not|
| Not Started† (N = 431)||Pregnant or mother (N = 923)||First pregnancy (N = 626)||Pregnant and Mother (N = 232)||Mother not Pregnant (N = 833)|
|a.% Knows at least two MC§||1951 (74.5)||54.6||76.0||70.1||77.8||85.6|
|b. % Has a preferred MC||1728 (72.2)||39.0||76.9||63.9||78.6||88.9|
| b.1. % Condom||14.1||31.5||16.8||16.6||8.8||7.5|
| b.2. % Oral contraceptives||28.2||32.3||30.1||32.8||21.1||24.6|
| b.3. % Injectables||43.7||28.5||48.3||41.1||43.5||44.2|
| b.4. % Intra-uterine device||13.7||6.2||4.7||9.5||25.2||23.5|
| b.5. % Sterilization||0.5||1.5||0.2||0.3||1.4||0.4|
|c. % Has ever used MC||1492 (57.2)||na||50.9||32.0||67.2||80.4|
| c1. % Purchased at Health Centre¶||773 (60.1)||na||39.7||42.0||78.7||75.5|
| c2. % Purchased at Pharmacy¶||570 (44.3)||na||62.8||55.7||22.0||33.3|
|d. % Currently using MC||528 (18.9)||na||23.4||0.8||2.2||46.7|
|e. % Who requests a MC††||1012 (33.2)||4.2||49.1||0.5||0.9||64.3|
| e1. % First time users of MC‡‡||350 (34.6)||100||45.3||100||0||23.2|
|f. % Using MC consulting for other reason§§||225 (7.4)||na||7.7||0.8||1.7||17.4|
|g. % Uses/plans to use MC after consultation||1237 (41.6)||4.2||56.8||1.3||2.6||81.8|
Nearly half of the sexually active girls who were neither pregnant nor mothers had never used contraceptives. Of the girls who were pregnant for the first time only 32% reported having ever used contraceptives.
The current use of contraceptives among sexually active girls who were neither pregnant nor mothers was only 24%. This percentage was strongly influenced by their civil state. The lowest use was seen among the singles (20%) and the highest among the married (34%). Among the girls who were already mothers, the use of contraceptives was higher (47%) and their civil state had no influence on their use (data not shown).
The health services were the most common supplier of contraceptives among girls who were already mothers (75.5%), while the pharmacy was more common among sexually active girls not yet mothers (63%).
Fifty-seven of the sexually active girls who were neither pregnant nor mothers and 82% of the non-pregnant mothers were using or requested a modern contraceptive method. Of those already using a modern method, 8% and 17% consulted for another reason, respectively.
Twenty-three per cent of the mothers who requested modern contraceptives had never used them before.
Four per cent who had not yet started sexual activity visited the doctor to request contraceptives to be protected at their sexual debut.
An overall result was that the intended use of contraceptives doubled among the sexually active non-pregnant voucher redeemers (from 24% to 57% among the girls not yet mothers and from 47% to 82% among the mothers, Table 3
). Sixty-nine per cent of the sexually active girls left with a contraceptive method.
Because of the late introduction of the question and the many missing values, only 510 sexually active non-pregnant girls were asked whether they intended to become pregnant in the next 12 months. Of these girls, 468 (92%) answered no, but, in fact, 77 (16.5%) were already pregnant.
The type of contraceptive method (oral, injectables, IUD, condoms) prescribed was in half the cases similar to the method indicated by the girls as their preferred type of method. The contraceptive methods most frequently prescribed were monthly injectables (Mesigyna®3, Schering, Berlin, Germany) (39%) and oral contraceptives (38.5%). Condoms were used by 8%. Of 528 girls who reported using contraceptives before redeeming their voucher, 141 (27%) consulted whether to change the type of method (not taking into account changes in kind of hormonal methods).
Overall, 5.5% of the girls who requested contraceptives left the clinic with no contraceptive method. This percentage ranged from 0% to 11% across different doctors, with younger female doctors (< 36 years) and older male doctors (> 35 years) having the lowest percentages (not shown). Some of the girls were instructed to come back on the first day of their menstruation. In other cases, no remarks were written down, which could explain the reason.
Who wants contraceptives?
Sixty-two per cent of the sexually active non-pregnant girls were currently using or requested contraceptives (Table 4). This percentage ranged from 43% to 96% according to which of the doctors was consulted (not shown). A multi-level logistic regression model was constructed to analyse which factors were associated with the actual or planned contraceptive use. Studying and having children were associated with a significantly higher use, and knowing two methods was associated with a nearly significant higher use. Girls assisted by young female doctors more frequently had contraceptives prescribed than those who were attended by female doctors older than 35 years or by male doctors younger than 35 years of age. Girls’ age group, status of relationship and having a preferred method were only significantly associated with the outcome in bivariate analysis (Table 4).
Table 4. Girl and provider-related factors related to the use or planned use of contraceptives among sexually active girls who are not pregnant
|Variables All||Category||N† 1456||% Uses MC‡ 906 (62.2)||Adjusted odds ratio§ (95% CI)|
|Knows two MC methods||No||281||52.0||1.00|
|Working and studying||109||55.0||0.85 (0.55–1.32)|
|At home||603||66.0||0.80 (0.57–1.14)|
|No. of children||0||778||51.0||1.00|
|2 or more||152||79.6||4.24 (2.83–6.38)|
|Gender/age of the doctor||Female doctors 35 years||821||67.4||1.00|
|Female doctors > 35 years||271||52.0||0.51 (0.30–0.88)|
|Male doctors 35 years||73||56.2||0.62 (0.44–0.89)|
|Male doctors > 35 years||291||58.8||0.73 (0.42–1.28)|