Behavioral Barriers to the Use of Modern Methods of Contraception among Unmarried Youth and Adolescents in Eastern Senegal: A Qualitative Study

"Interventions aimed at increasing uptake of contraceptives among unmarried young people in eastern Senegal must address several significant behavioral barriers in addition to structural, informational, and socio-cultural barriers in order to be successful."

The purpose of this qualitative study was to gain insight into the behavioural barriers that prevent unmarried young people in eastern Senegal from using modern methods of contraception. In contrast to standard economic models of behaviour that assume that people always carefully weigh the benefits and disadvantages of each decision and action, the behavioural approach, which informs the study, examines the ways in which cognitive biases and heuristics interact with features of the environment to impact our choices and actions.

The study was conducted as part of the United States Agency for International Development (USAID)-funded Neema project, with the ultimate aim of designing and testing an intervention to reduce unintended pregnancies among unmarried young people in the Kedougou and Tambacounda regions of Senegal. These regions have particularly high rates of childbearing among young women and a low modern contraceptive prevalence rate (MCPR).

In 2017, the research team conducted 48 in-depth individual interviews with unmarried youth aged 15-24 and parents of youth aged 10-24, as well as 5 sex-segregated focus groups with 6-9 young people per group. The team then conducted a thematic content analysis and synthesised the findings by major theme. Drawing insights from behavioural science, the analysis yielded 5 key findings about unmarried young people. They:

1. Avoid making a decision about contraception because thinking about contraceptive use provokes uncomfortable associations with a negative identity (i.e., being sexually active before marriage in a context in which abstinence is promoted as the optimal behaviour). Contraceptives are seen as a last resort option used only by youth who are promiscuous, lacking in discipline, or unfaithful to their partners.
2. See modern methods as inappropriate for people like them. Modern methods of contraception are seen as appropriate for married women with children who would like to space their births.
3. Are overconfident in their ability to prevent pregnancy through traditional (e.g., withdrawal) and folk methods (e.g., amulets). Many young people do not see modern methods as a more effective replacement for traditional and folk methods but, rather, as an equal alternative.
4. Overestimate the social and health risks of modern contraceptive methods. For example, while many young people think community members would unconditionally disapprove of their use of contraception, many parents they would support it if their child were at a high risk for pregnancy.
5. Fail to plan ahead and are not prepared to use modern contraceptive methods before every sexual encounter. In Kedougou and Tambacounda, discussion of sex and contraceptives is considered taboo. Because men can decline their responsibility for the pregnancy, ensuring they use protection with every sexual encounter may not feel like a high priority.

As the paper outlines, each of these barriers is facilitated or exacerbated by cognitive biases, leading youth to avoid making a decision about contraception, decide not to use contraception, or fail to follow through on an intention to use contraception during every sexual interaction. For example, "In a society that views premarital sex as categorically negative, thinking about contraception causes cognitive dissonance - a mental discomfort with any action that contrasts with one's identity, values, or beliefs - leading youth to avoid seeking information about or making a decision to use contraception..." Furthermore, youth may decide not to use contraception due to erroneous estimations of the risks and benefits of doing so, which are likely to be impacted by incorrect mental models, overconfidence, present bias, and the availability heuristic. To elaborate on the latter type of bias: People use mental shortcuts to evaluate risks in which we perceive risks that come to mind easily as more likely to occur. Across sub-Saharan Africa, women who are not able to bear children are significantly devalued and face negative psycho-social outcomes; for a young woman, any risk that would endanger her future fertility, however small, is to be avoided.

Based on this analysis, the paper lays out programmatic implications. For instance, the researchers note that standard interventions - e.g., those that combine health worker training, adolescent-friendly facility improvements, and information dissemination - may fail to significantly shift youth behaviour in part because they do not address behavioural barriers in addition to informational and structural barriers. One promising way forward, the researchers argue, would be to create "a moment of choice for young people to thoughtfully consider their pregnancy risk and whether contraceptives might be beneficial for them. In order to counteract the behavioral barriers described in this report, it would be critical in this moment to highlight positive identities of a young contraceptive user (e.g., responsible for future, choosing when to have a baby in order to have a healthier baby), reframe the norm about intended users of modern methods to include unmarried women and youth, and dispel common myths about the side effects of modern methods. For youth who have decided to use contraception, the design should include concrete and actionable plan-making tools and timely reminders in order to help youth follow through on their intentions."

In that vein, the research team designed an intervention informed by the findings in this report that they argue "is feasible to implement, increases youth visits to health facilities, and has the potential to shift youth contraceptive behavior." For the intervention, which was tested as a pilot in 5 health facilities in Tambacounda with over 200 youth, youth are given appointments for a free wellness checkup with the local nurse or midwife. The checkup includes several low-stigma themes relevant for youth (such as exercise and nutrition), in addition to carefully framed reproductive health questions and messages that aim to challenge myths about contraception and help youth make a thoughtful, well-informed contraceptive choice.

In conclusion, in order to be successful, interventions designed to increase contraceptive use among youth in eastern Senegal or similar populations are advised to "facilitate an informed and deliberate decision about contraceptive needs, lower the perceived health and social risks of accessing reproductive health information and services, highlight the benefits of modern methods over traditional and folk methods, and aid follow-through on intentions to access and use contraception."