RESEARCH

A study of the attitude and knowledge of teenagers in the

Pietermaritzburg area towards contraception
P Israel, MB BCh, FCOG (SA); T D Naidoo, FCOG (SA), PhD; M J Titus, MB ChB, FCOG (SA), LLM, PG Dip Int Res Ethics

Department of Obstetrics and Gynaecology, Grey’s Hospital, Pietermaritzburg, South Africa

Corresponding author: P Israel (priya.israel@kznhealth.gov.za)

Background. Preventing teenage pregnancy is an important means of improving adolescent health and reducing perinatal mortality.
Objectives. To improve our understanding of teenagers’ attitudes towards and knowledge about contraception, access to contraception
and sexual activity in our health district.
Methods. A descriptive, cross-sectional, questionnaire-based study analysed demographic data, knowledge about, access to and use of
contraceptives and knowledge about sexually transmitted infections (STIs) in teenagers from 13 to 17 years of age in seven schools in the
Pietermaritzburg area, KwaZulu-Natal, South Africa.
Results. Of the 350 participants who answered the questionnaire completely, 24.9% reported being sexually active, of whom 70.1% used
contraception. Knowledge about emergency contraception (EC) was generally poor (8.7%). Sexually active respondents were more aware
of condoms (78.6% v. 56.9%), injectable contraception (57.4% v. 41.8%) and EC (14.6% v. 6.1%) than those who were not. Knowledge
about STIs was generally good (71.7%) and improved with increasing grade at school. Males had a better understanding of condoms
being protective against STIs than females (60.8% v. 39.4%).
Conclusion. Knowledge about condoms and injectable and oral contraception is adequate, whereas that about EC and dual
contraception needs to be improved. Use of contraceptives other than condoms is poor, indicating a disparity between knowledge and
use.
S Afr J Obstet Gynaecol 2016;22(1):25-28. DOI:10.7196/SAJOG.2016.v22i1.1044

The World Health Organization recognises adolescent fertility knowledge regarding the causes of and protection against HIV and
regulation and pregnancy prevention as one of the most important STIs.
healthcare concerns of the 21st century.[1] Correct and consistent The literature suggests there is no single intervention that is
use of dual contraception prevents or reduces the incidence of universally effective in reducing the impact of unprotected sexual
teenage pregnancy and HIV transmission.[2] The rates of teenage intercourse. The best chance lies in developing tailored strategies
pregnancy and HIV transmission in South Africa (SA) remain high, to suit the community environment.[4] We therefore conducted
highlighting a need to address poor use of contraceptives among this study in our teenage population to assess their knowledge and
sexually active teenagers.[1] attitudes towards contraception and STIs.
Causes of unprotected sexual intercourse are multifactorial: poor
sex education, incorrect and inconsistent contraceptive use, attitudes Objectives
of healthcare workers (HCWs), poor access to contraceptive To determine knowledge about contraception among teenagers in
services, gender inequality and sexual taboos.[3] Trans-generational the Pietermaritzburg (PMB) area, to determine attitudes towards
sexual relationships in which girls engage in transactional sexual activity and access to contraception, and to determine
relationships with older men contribute to teenage pregnancy and knowledge about HIV and STIs and how contraception may help to
HIV acquisition.[4] prevent spread.
Contraception is freely available from government clinics as per
the National Contraception Policy Guidelines.[2] These allow for Methods
a variety of contraceptives to be offered and for information to be A descriptive cross-sectional questionnaire-based study was
dispensed in a confidential, non-judgemental manner. used. All non-pregnant persons aged 13 - 17 years were eligible to
A local study found that clinic staff and hours were obstacles participate.
to use of contraception and that HCWs did not allow teenagers The study was conducted in PMB, the capital city of KZN. We
to choose their contraceptives.[5] Jewkes et al.[6] found that 5% of aimed for a target sample size of 800, 100 per school. Of the initial
teenagers reported HCW attitudes as a problem, while Bana et al.[7] eight schools selected, one was excluded because the questionnaire
revealed that in 54% of cases fear of parents finding out was a barrier needed to be administered individually by means of personal
to contraceptive use. interviews with each pupil. Owing to time constraints this was not
In 2008, a national population-based survey revealed that the possible. A total of 630 questionnaires were distributed, of which
national HIV prevalence among 15 - 24-year-olds was 8.7%; 371 were returned. Of these, 21 were excluded because they did
however, in KwaZulu-Natal (KZN), SA, the rate was 15.3% in this not meet the age criteria. This left a total of 350 completed eligible
age group.[8] questionnaires, which represented a 55.6% response rate.
James et al.,[9] in their study of secondary school learners in The research instrument was a non-validated, peer-reviewed,
the Midlands of KZN, found that teenagers had a high level of self-administered questionnaire (available in English and isiZulu).

SAJOG • September 2016, Vol. 22, No. 1 25

Data were collected in June 2013. Interested population reporting being sexually active, Half of the girls (50.2%) were aware of DC
learners were given consent forms for their 17.1% of girls and 44.4% of boys (Table 1). compared with 29.8% of the boys (p=0.003).
parents/guardians to sign and information Of the sexually active population 70.1%
leaflets on the study. Completed consent were using contraception (60.4% of sexually Access to contraceptives
forms were collected and the questionnaires active girls and 79.5% of boys reported Eighty-four per cent of the total study
were distributed to those who were eligible. using contraception). The proportion of population, and 86.2% of the sexually
Data were transcribed onto an MS Excel boys using contraception increased with active population reported they would
spreadsheet (Microsoft, USA). This was age; however, among the girls there was a access contraception from a clinic; 51.0%
imported into the statistical software and decrease in contraceptive use between the reported having good access to contraceptive
used and coded appropriately, after which ages of 14 and 16 years. services, while 35.0% felt that their access
the biostatistician performed statistical Condoms, the most commonly used was poor. Of the boys, 48.8% compared with
support and analysis. SPSS version 19.0 contraceptive among both boys and girls, 51.9% of girls felt they had good access to
(IBM Corp., USA) was used. A p-value were used by 87.3%. Injectable and oral contraceptive services, and 40.0% of grade
of <0.05 was considered statistically contraception were each being used by 8s (13 - 14-year-olds) reported having good
significant. Results were summarised by 6.8%. Only 3.4% reported using dual access to contraceptive services compared
frequencies and percentages for categorical contraception (DC) and 1.7% emergency with 61.0% of grade 12s (17 years old).
data, and means, medians, standard contraception (EC).
deviations or percentiles for continuous Of the 6.8% who were using injectable Contraception: seeking
numerical data. Normally distributed data contraception, all were 17 years old. Of the advice, barriers and
were analysed using Student’s t-test when 6.8% who were using oral contraceptives, knowledge about emergency
comparing two groups. Pearson’s χ2 test or 3.4% were 16 years old and 3.4% were 17. contraception
Fischer’s exact test were used to identify Of those who were using EC and DC, all Table 4 shows the age, gender and sexually
trends between categorical variables as were 17 years old. The only contraceptive active groups and the barriers that they
appropriate. that the 14-year-olds reported using was reported to seeking contraceptive advice.
condoms, whereas the 17-year-olds used a There was a significant difference in
Ethical approval variety of contraceptives. terms of gender and being embarrassed,
Ethical approval was obtained from the The best-known contraceptive method with more girls reporting it as a barrier.
Biomedical Research Ethics Committee of was the condom (Table 2). Those who Fear of parents or teachers finding out was
the University of KwaZulu-Natal. Written were sexually active were more aware of the most common barrier, for which there
consent was obtained from the Head of the condoms than those who were not (78.6% v. was no difference across ages, gender or
Department of Education for KZN. Written 56.9%; p<0.001) (Table 3). sexually active groups.
consent was obtained from parents or Knowledge about the intrauterine Most teenagers would seek advice from
guardians for their child/ward to participate. contraceptive device (IUCD), bilateral an HCW. Those who had an idea of what EC
tubal ligation (BTL), the patch and EC was best understood it as being the use of the
Results was generally poor. Of those who were ‘morning-after pill’; 42.8% of respondents
The median age of sexual debut was not sexually active, 6.1% (v. 14.6% of those were unsure of when EC should be taken.
15  years, with 24.9% of the study who were) were aware of EC (p=0.028). Knowledge about EC gradually increased
with age. More girls than boys knew about
EC (35.0% v. 21.3%); 26.2% of those who
Table 1. Gender and sexually active distribution of the study population according to were not sexually active understood EC to
age and grade be the ‘morning-after pill’ compared with
n (%) Males, n (sexually active)* Females, n (sexually active)* 44.1% of those who were sexually active.
Age (years)

13 31 (8.9) 7 (0) 24 (0) Table 2. Knowledge about

14 51 (14.6) 17 (2) 34 (1) contraception (N=254)*
15 81 (23.1) 18 (5) 63 (9) Type of contraception n (%)
16 94 (26.9) 26 (12) 68 (11) Condom 161 (63.4)
17 93 (26.6) 31 (25) 62 (22) Injection 120 (47.2)
Total 350 99 (44) 251 (43) Pill 115 (45.3)
Grade DC 112 (44.1)
8 80 (22.9) 31 (2) 49 (0) EC 22 (8.7)
9 70 (20.0) 19 (8) 51 (7) Abstinence 18 (7.1)
10 89 (25.4) 23 (13) 66 (10) IUCD 8 (3.1)
11 74 (21.1) 14 (11) 60 (14) Patch 1 (0.4)
12 37 (10.6) 12 (10) 25 (12) BTL 1 (0.4)
*Numbers in brackets indicate the number of sexually active teenagers in each group. *Only 254 of the 350 respondents answered these questions.

26 SAJOG • September 2016, Vol. 22, No. 1

 Table 3. Knowledge about various contraceptive methods by age, educational grade, gender and sexually activity (N=254)*
N Condoms, n p-value Injectables, n p-value Pills, n p-value EC, n p-value DC, n p-value
Age (years) 0.016 0.018 0.030 0.198 0.005
13 13 7 3 4 0 4
14 39 19 12 12 1 10
15 58 34 30 23 4 22
16 73 45 33 34 7 33
17 71 7 42 42 10 43
Grade 0.001 0.000 0.030 0.010 0.000
8 39 17 7 4 0 7
9 64 43 33 12 1 25
10 61 31 20 23 8 20
11 58 44 37 34 9 37
12 32 26 23 42 4 23
Gender 0.020 0.000 0.007 0.418 0.030
Male 77 57 20 25 5 23
Female 177 104 100 90 17 89
Sexually active 0.001 0.018 0.264 0.028 0.276
Yes 75 59 44 38 11 37
No 179 102 76 77 11 75
*Only 254 of the 350 respondents answered these particular questions.

Knowledge about sexually transmitted Overall, we showed that contraception was being used, most
infections commonly condoms, but use of other methods of contraception was
Most respondents knew about STIs; 75.3% of the sexually active and poor.
70.4% of those who were not sexually active correctly identified an In the USA, one successful approach has been the use of long-
STI as a disease acquired after unprotected sexual intercourse. Of acting reversible contraception.[11] Implementation of this strategy in
the sexually active, 55.4% knew that contraception was protective, SA may help to reduce the rate of teenage pregnancy.
compared with 42.1% of those who were not. Among 14-year-olds the only contraceptive being used was the
Most respondents identified condoms as being protective against condom. Possible explanations for this include a lack of access to
STIs. Boys had a better understanding of condoms being protective a variety of contraceptives on account of discrimination at local
against STIs compared with girls (60.8% v. 39.4%). School clinics, fear of being punished by parents or teachers, and poor
grade was found to be significantly associated with knowledge knowledge about contraceptive options.
about condoms being protective against STIs. This question Emergency, dual and injectable contraception use was limited
was generally correctly answered by all grades, except grade 10 to 17-year-olds. Consistent with this was that knowledge about EC
(15 - 16-year-olds), where only 53.3% knew that a condom was was generally poor. While dual and injectable contraceptives were
protective against STIs. reasonably well known, their use was low, indicating a disparity
The three most commonly reported problems that were associated between knowledge and practice.
with teenage pregnancy were financial and related to health and Condoms were the best-known contraceptive, which was
education. Improving awareness of contraception and increasing predictable given the mass media attention they receive coupled
availability were the two most common suggestions for improving with their unrestricted availability. Significantly more boys than
contraceptive services. girls reported knowledge about condoms, and more boys than girls
knew that condoms were protective against acquiring STIs. The use
Discussion of condoms is protective (against STIs) for both the male and female
Our study showed a low rate of sexual activity (24.9%) compared partner in a sexual encounter, and the results suggest that boys are
with others. This may be due to under-reporting of sexual activity aware of this protective benefit. Girls knew more about injectable,
out of fear of parents or teachers finding out. Implementation of the oral and dual contraception than boys, perhaps because they
abstinence-based approach to teenage pregnancy as outlined in the exclusively utilise these forms of contraception.
Department of Basic Education’s ‘Measures for the prevention and Our findings suggest that sexually active teenagers have a greater
management of learner pregnancy’[10] may be another explanation. knowledge about condoms, injectable and emergency contraception
A high percentage of sexually active teenagers reported use of than those who were not. If this is a true reflection of the general
condoms. This finding is in keeping with the study by Shisana et teenage population, one may speculate that being sexually active
al.[8] that also showed high rates of condom use. There was a steady influences a teenager’s decision to pursue and retain knowledge
increase in contraceptive use among boys as age increased. about contraception.

SAJOG • September 2016, Vol. 22, No. 1 27

 above any other person. This information is of paramount relevance
Table 4. Knowledge about most reliable contraceptive, whom to the public health sector, where it is possible to evaluate, revise and
teenagers are most likely to seek advice from, barriers to regulate standards of service provision.
contraceptive use and knowledge about EC Fear of parents or teachers finding out was the most common
n (%) reason for not seeking contraceptive advice. Expanding the
Most reliable contraceptive (N=271)* availability of adolescent-friendly clinics that provide confidential
Condom 57 (21.0)
services may be a solution to this problem.
Those who were sexually active were more likely than those
Pill 37 (13.7)
who were not to know that condoms were protective against
Abstinence 36 (13.3)
STIs. This suggests that sexually active teenagers have a
Injection 35 (13.0) better knowledge about how to protect themselves against the
None 6 (2.2) infections for which they are at risk. Girls reported having better
EC 3 (1.1) access to contraceptive services than boys, which is reassuring
BTL 2 (0.7) since it is they who carry the burden of teenage pregnancy.
Access was reported to be lowest among grade 8 (14-year-old)
Advice from (N=330)*
learners, which may be due to discrimination against younger
HCW 180 (54.5)
teenagers by HCWs.
Parent 58 (17.6) Several suggestions were made regarding how to improve current
Friend 56 (17.0) contraceptive services, the most common of which were to increase
Teacher 49 (14.8) awareness and availability of contraception. Though controversial,
Sibling 26 (7.9) one approach to promoting adolescent sexual and reproductive
Unknown 23 (7.0) health would be to provide contraceptive education and services at
schools.
Nobody 8 (2.4)
Books 4 (1.2)
Conclusion
Google 2 (0.6) Knowledge about condoms and injectable and oral contraception
Barriers to contraception (N=311)* was adequate, but needs to be improved on for EC and DC. Use of
Fear of parents and teachers 154 (49.5) contraceptives other than condoms is poor, indicating a disparity
Embarrassment 137 (44.1) between knowledge and use. Teenage pregnancy is a major public
health concern and much attention has been focused on improving
Lack of health facilities 28 (9.0)
contraceptive services for this vulnerable group. Implementation of
Other 10 (3.2)
the various laws, policies and programmes remains erratic at best.
Unknown 1 (0.3) If we are ever to achieve the national and international targets of
EC knowledge (N=275)* improving maternal and child health, efforts to escalate and improve
Unsure 98 (35.6) sexual and reproductive health services for teenagers will need to be
Morning-after pill 86 (31.3) intensified.
Condoms 50 (18.2)
Pills 16 (5.8)
References
Termination of pregnancy 12 (4.4)
1. Department of Child and Adolescent Health and Development, World Health Organization
Injections 8 (2.9) (WHO). Contraception Issues in Adolescent Health and Development. Geneva: WHO, 2004.
2. National Department of Health, South Africa. National Contraception and Family Planning Policy
After rape 7 (2.5) and Service Delivery Guidelines. Pretoria: NDoH, 2012.
3. Nalwadda G, Mirembe F, Byamugisha J, Faxelid B. Persistent high fertility in Uganda: Young people
Before sex 1 (0.4) recount obstacles and enabling factors to use of contraception. BMC Public Health 2010;10:530.
DOI:10.1186/1471-2458-10-530
Within 24 hours 1 (0.4)
4. Oni TE, Prinsloo EAM, Nortje JD, Joubert G. High school students’ attitudes, practices and
When to take EC (N=278)* knowledge of contraception in Jozini, KwaZulu-Natal. S Afr Fam Pract 2005;47(6):54-57. DOI:10.
1080/20786204.2005.10873247
Unsure 119 (42.8) 5. Hoffman-Wanderer Y, Carmody L, Chai J, Röhrs S. Condoms? Yes! Sex? No! Conflicting
Responsibilities for Healthcare Professionals Under South Africa’s Framework on Reproductive
After sex 82 (29.5) Rights. Cape Town: Gender Health and Justice Research Unit, University of Cape Town. 2013.
http://www.ghjru.uct.ac.za/sites/default/files/image_tool/images/242/documents/Condoms_Yes_
Before sex 26 (9.4) Sex_ No.pdf (accessed 24 March2014).
6. Jewkes R, Morrell R, Christofides N. Empowering teenagers to prevent pregnancy: Lessons from
The morning after 20 (7.2) South Africa. Culture, Health & Sexuality 2009;11(7):675-688. DOI:10.1080/13691050902846452
7. Bana A, Bhat VG, Godlwana X, et al. Knowledge, attitudes and behaviours of adolescents in relation
Within 72 hours 17 (6.1) to STIs, pregnancy, contraceptive utilization and substance abuse in the Mhlakulo region, Eastern
Cape. S Afr Fam Pract 2010;52(2):154-158. DOI:10.1080/20786204.2010.10873959
After rape 14 (5.0) 8. Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence, Incidence, Behaviour
and Communication Survey 2008: A Turning Tide Among Teenagers? Cape Town: HSRC Press,
Within 24 hours 5 (1.8) 2009.
*The number of respondents who answered each question varied. 9. James S, Reddy SP, Taylor M, Jinabhai CC. Young people, HIV/ AIDS/ STIs and sexuality
in SA: The gap between awareness and behaviour. Acta Paediatr 2004;93(2):264-269.
DOI:10.1111/j.1651-2227.2004.tb00718.x
10. National Department of Education, South Africa. Measures for the prevention and management of
learner pregnancy. 2007. www.education.gov.za (accessed 7 November 2013).
The most common reported access point for contraception was the 11. Elfenbein DS, Felice ME. Adolescent pregnancy. Pediatr Clin North Am 2003;50(3):781-800.
clinic. Most teenagers reported they would ask an HCW for advice DOI:10.1016/s0031-3955(03)00069-5

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