A qualitative participatory study on adolescent girls’ access to contraception and other sexual and reproductive health services in rural Sierra Leone

Abstract

Sierra Leone has one of the highest adolescent birth rates globally (approximately 101 per 1000 girls aged 15–19 years). Despite documented barriers to sexual and reproductive health (SRH) service access in sub-Saharan Africa, qualitative evidence specific to rural Sierra Leone particularly evidence generated through participatory methods involving adolescent girls remains limited. This study explored how adolescent girls experience SRH service access in rural Sierra Leone, with specific attention to the social and institutional mechanisms that suppress help-seeking. A qualitative participatory design was employed across three rural districts (Koinadugu, Moyamba, Pujehun) between February and July 2024. Eighty-seven participants were engaged through in-depth interviews (IDIs), focus group discussions (FGDs), guided storytelling, and service-access journey mapping. The primary analytic group comprised 32 adolescent girls aged 15–19 years. These 32 girls were the primary analytic focus, while the remaining 55 participants (young mothers, parents and guardians, teachers, community health workers, nurses and midwives, youth leaders, and community and religious leaders) provided complementary perspectives that enabled triangulation. IDIs were conducted with adolescent girls and young mothers, FGDs with the community stakeholder groups, and guided storytelling and journey mapping with adolescent girls. Guided by the socio-ecological model, data were analysed using reflexive thematic analysis. Four themes, each encompassing specific findings, were generated: (1) internalised shame and community surveillance as co-constitutive barriers to help-seeking; (2) provider disclosure as a systemic confidentiality failure with community-wide deterrent effects; (3) compounding structural barriers including judgmental provider attitudes, contraceptive stockouts, provider-generated misinformation, and geographic inaccessibility; and (4) pregnancy as an effective terminator of educational trajectories despite formal policy protections. Journey mapping data distinctively illustrated how girls spatially navigate exposure risk at health facilities. Adolescent girls in rural Sierra Leone are excluded from contraceptive and other SRH services by four interlocking mechanisms identified here: internalised shame reinforced by community surveillance; provider disclosure that breaches confidentiality and deters entire peer networks; compounding structural barriers including judgmental provider attitudes, contraceptive stockouts, and provider-generated misinformation; and the effective loss of schooling following pregnancy. clear confidentiality protocols, provider behaviour change strategies that extend beyond training to enforceable service defaults, supportive supervision, and recognition of non-judgmental care. Other recommendations are reliable contraceptive supply, self-care and community-based delivery channels that lower the exposure cost of obtaining contraception, comprehensive sexual and reproductive health and rights literacy paired with peer advocacy, community engagement, and enforcement of the policy that allows pregnant girls to return to school. Sierra Leone has one of the highest adolescent birth rates globally (approximately 101 per 1000 girls aged 15–19 years). Despite documented barriers to sexual and reproductive health (SRH) service access in sub-Saharan Africa, qualitative evidence specific to rural Sierra Leone particularly evidence generated through participatory methods involving adolescent girls remains limited. This study explored how adolescent girls experience SRH service access in rural Sierra Leone, with specific attention to the social and institutional mechanisms that suppress help-seeking. A qualitative participatory design was employed across three rural districts (Koinadugu, Moyamba, Pujehun) between February and July 2024. Eighty-seven participants were engaged through in-depth interviews (IDIs), focus group discussions (FGDs), guided storytelling, and service-access journey mapping. The primary analytic group comprised 32 adolescent girls aged 15–19 years. These 32 girls were the primary analytic focus, while the remaining 55 participants (young mothers, parents and guardians, teachers, community health workers, nurses and midwives, youth leaders, and community and religious leaders) provided complementary perspectives that enabled triangulation. IDIs were conducted with adolescent girls and young mothers, FGDs with the community stakeholder groups, and guided storytelling and journey mapping with adolescent girls. Guided by the socio-ecological model, data were analysed using reflexive thematic analysis. Four themes, each encompassing specific findings, were generated: (1) internalised shame and community surveillance as co-constitutive barriers to help-seeking; (2) provider disclosure as a systemic confidentiality failure with community-wide deterrent effects; (3) compounding structural barriers including judgmental provider attitudes, contraceptive stockouts, provider-generated misinformation, and geographic inaccessibility; and (4) pregnancy as an effective terminator of educational trajectories despite formal policy protections. Journey mapping data distinctively illustrated how girls spatially navigate exposure risk at health facilities. Adolescent girls in rural Sierra Leone are excluded from contraceptive and other SRH services by four interlocking mechanisms identified here: internalised shame reinforced by community surveillance; provider disclosure that breaches confidentiality and deters entire peer networks; compounding structural barriers including judgmental provider attitudes, contraceptive stockouts, and provider-generated misinformation; and the effective loss of schooling following pregnancy. clear confidentiality protocols, provider behaviour change strategies that extend beyond training to enforceable service defaults, supportive supervision, and recognition of non-judgmental care. Other recommendations are reliable contraceptive supply, self-care and community-based delivery channels that lower the exposure cost of obtaining contraception, comprehensive sexual and reproductive health and rights literacy paired with peer advocacy, community engagement, and enforcement of the policy that allows pregnant girls to return to school. Sierra Leone has one of the highest adolescent birth rates globally (approximately 101 per 1000 girls aged 15–19 years). Despite documented barriers to sexual and reproductive health (SRH) service access in sub-Saharan Africa, qualitative evidence specific to rural Sierra Leone particularly evidence generated through participatory methods involving adolescent girls remains limited. This study explored how adolescent girls experience SRH service access in rural Sierra Leone, with specific attention to the social and institutional mechanisms that suppress help-seeking. A qualitative participatory design was employed across three rural districts (Koinadugu, Moyamba, Pujehun) between February and July 2024. Eighty-seven participants were engaged through in-depth interviews (IDIs), focus group discussions (FGDs), guided storytelling, and service-access journey mapping. The primary analytic group comprised 32 adolescent girls aged 15–19 years. These 32 girls were the primary analytic focus, while the remaining 55 participants (young mothers, parents and guardians, teachers, community health workers, nurses and midwives, youth leaders, and community and religious leaders) provided complementary perspectives that enabled triangulation. IDIs were conducted with adolescent girls and young mothers, FGDs with the community stakeholder groups, and guided storytelling and journey mapping with adolescent girls. Guided by the socio-ecological model, data were analysed using reflexive thematic analysis. Four themes, each encompassing specific findings, were generated: (1) internalised shame and community surveillance as co-constitutive barriers to help-seeking; (2) provider disclosure as a systemic confidentiality failure with community-wide deterrent effects; (3) compounding structural barriers including judgmental provider attitudes, contraceptive stockouts, provider-generated misinformation, and geographic inaccessibility; and (4) pregnancy as an effective terminator of educational trajectories despite formal policy protections. Journey mapping data distinctively illustrated how girls spatially navigate exposure risk at health facilities. Adolescent girls in rural Sierra Leone are excluded from contraceptive and other SRH services by four interlocking mechanisms identified here: internalised shame reinforced by community surveillance; provider disclosure that breaches confidentiality and deters entire peer networks; compounding structural barriers including judgmental provider attitudes, contraceptive stockouts, and provider-generated misinformation; and the effective loss of schooling following pregnancy. clear confidentiality protocols, provider behaviour change strategies that extend beyond training to enforceable service defaults, supportive supervision, and recognition of non-judgmental care. Other recommendations are reliable contraceptive supply, self-care and community-based delivery channels that lower the exposure cost of obtaining contraception, comprehensive sexual and reproductive health and rights literacy paired with peer advocacy, community engagement, and enforcement of the policy that allows pregnant girls to return to school.