Introduction

Young women in Haiti experience high pregnancy rates, with 53 annual births per 1,000 adolescents (ages 15–19) [1] in 2021, and 10% reported having children or being currently pregnant in 2017, many of which are unintended [2,3,4]. Unmet need for contraception contributed to an estimated 413,000 unintended pregnancies in Haiti in 2019 [5], which are in turn associated with adverse outcomes such as increased rates of unsafe abortions and increased risk of maternal complications or mortality [6]. Haiti’s maternal mortality rates remain disproportionally high with 480 deaths per 100,000 live births, compared to neighboring Dominican Republic and Cuba (95 and 36 and per 100,000 live births respectively) [7]. A study of 172 countries found at least 30% of maternal deaths, 45% specifically in Haiti, could be prevented by meeting needs for unmet contraception use [8]. Closing the gap between contraception needs and access could result in numerous positive outcomes for adolescents in Haiti, who report unique physical, economic, and psychosocial challenges with unintended pregnancies and subsequent transition to parenthood [9, 10].

Healthcare providers (HCPs) play an important role in facilitating contraception access and use. Though World Health Organization guidelines recommend pregnancy prevention care including autonomy supportive contraceptive when desired [11], many HCPs do not provide this evidence-based care for adolescents [12]. HCPs may have moral or social reservations about discussing contraception with adolescents [13, 14] and also may not have the knowledge or training to counsel about the full range of contraception options, particularly long acting reversible contraception (LARC). To our knowledge only one study has examined HCP contraception perceptions in Haiti. The study focused on postpartum women living in Northern Haiti and identified provider-level barriers, including insufficient knowledge and lack of time or privacy and highlighted younger women as particularly vulnerable [15]. No studies have examined the perceptions of HCPs regarding contraception use among adolescent women in Haiti, particularly in rural communities. As Haitian policy requires public health clinics to provide free contraception services [2], it is critical to examine what barriers impact HCP provision of this critical care.

The goal of this mixed-methods study was to describe HCPs’ attitudes, subjective norms and perceived behavioral control related to contraceptive care for adolescents (ages 14–18) in rural Haiti.

Methods

Study design

We conducted a cross-sectional survey and qualitative interviews of HCPs in rural Haiti from August 2021 to March 2022. Surveys and interviews were based on the Theory of Planned Behavior (TPB), a theoretical framework which asserts that behavioral intention is driven by attitudes (e.g., beliefs and values), subjective norms (e.g., influence of important peers, personal experience), and perceived behavior control (e.g., barriers and facilitators of the behavior) [16,17,18]. The TPB is a comprehensive model that has been widely used to describe healthcare provider influence on health behaviors that are driven strongly by behavioral intention, including sexual health behaviors and contraception use (Fig. 1).

Fig. 1
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The TPB is adapted to model the provision of sexual and reproductive healthcare to adolescents and young adults

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Inclusion criteria for HCPs included clinical staff (e.g., nurses, nurse midwives, physicians, other) who engage in reproductive health care at a clinic or hospital affiliated with one of our partner organizations, Global Birthing Home Foundation and Hospital Albert Schweitzer. Global Birthing Home Foundation is a free-standing maternal health center in the Southern Department of Haiti staffed by Haitian nurse midwives who offer contraceptive care, as well as prenatal, labor and delivery and postnatal care. High risk patients and pregnancies are referred for obstetric/gynecologist care at the regional hospital. Hospital Albert Schweitzer is a community hospital in the Central Department of Haiti that offers reproductive and obstetric care by obstetric/gynecologist physicians and nurse midwives. This hospital operates several community health centers in the region that also offer contraceptive care. Global Birthing Home Foundation and Hospital Albert Schweitzer have no affiliation with one another. This study was conducted concurrently with our previously published study on Haitian adolescents and young adults (AYAs, ages 14–24) perspectives on contraception [10].

The study was reviewed (including study protocol, all study documents and verbal consent process) and approved by the institutional review board at the affiliated academic institution, Children’s Mercy Hospital, Kansas City, MO, in the United States and by an administrative leader at each study site (Global Birthing Home Foundation, Hospital Albert Schweitzer) according to local procedures in Haiti. Study materials were first reviewed by our study team, including our co-investigator and bilingual university-level translator (DC) who is a Haitian young adult female and native to the community where Global Birth Home Foundation is located. Her feedback informed changes to the survey and interview guides to ensure the cultural appropriateness of our study materials. All study materials were created in English and translated into Haitian Creole by our previously described co-investigator (DC). Translated documents were reviewed and revised by the local research team in Haiti and with three HCPs representative of the sample to ensure accuracy and comprehension. Verbal consent and data collection were conducted in Haitian Creole.

Procedures

The research team included two local research assistants (i.e., young adult females fluent in Haitian Creole) who were trained in study procedures (i.e., verbal consent, survey and interview administration, data collection). The research assistants worked with staff at each healthcare facility to recruit a convenience sample of eligible HCPs. They approached eligible staff at their place of work at a convenient time during the workday and obtained verbal consent to participate. Due to procedural error, we did not capture the number of declinations and reasons for declination. Participants were given the choice to privately self-administer or to complete the survey administered by the research assistants privately on a tablet with no identifiable information collected. Study data were entered and managed using Research Electronic Data Capture (REDCap) hosted at Children’s Mercy Hospital [19, 20]. Upon survey completion, a sub-sample of HCPs were then asked to complete a semi-structured audio-recorded interview until reaching a sample size expected to achieve thematic saturation [21]. The survey and interview took approximately thirty minutes each to complete. All HCP participants were given a phone card worth $5 US upon completion of study activities (i.e., survey, or survey and interview).

Survey instrument

We developed a survey using previously validated instruments (more details below) to assess HCP demographics, clinical experience and practice behaviors, as well as 46 items assessing TPB [5] constructs including attitudes, subjective norms, and perceived behavioral control regarding contraceptive care for adolescents (see appendix) [22,23,24].

Demographics and clinical experience

We used multiple choice questions to assess demographic information including age and training background. To assess practice behaviors, participants reported their estimated frequency of obtaining a sexual history when caring for adolescents using a 5-point Likert scale (“always,” “very often,” “sometimes,” “rarely,” or “never”) and their estimated frequency of caring for adolescents with a comorbid condition associated with possible pregnancy complications (categorized as 0, 1–5, 6–10, 11–20, and > 20%). We also assessed interest in further education in taking a sexual history and contraception provision using a 5-point Likert scale (“extremely,” “moderately,” “somewhat,” “slightly,” or “not at all”).

Attitudes

To assess attitudes, participants reported how strongly they agreed or disagreed with statements about the provision of sexual health services that are appropriate to offer adolescents in their clinical settings (e.g., counseling for pregnancy prevention, safer sexual behaviors, or condom use).

Subjective norms

To assess subjective norms, one survey item asked about sources of information that inform HCP’s reproductive care for adolescents (“Which of the following do you consider when providing reproductive care to an adolescent in your practice?” (e.g., informal guidelines, national guidelines).

Perceived behavioral control

To assess perceived behavioral control we focused on multi-level barriers. To assess this, participants responded to survey items about barriers on the levels of individual provider (e.g., insufficient knowledge), patient (e.g., fear of disclosure to parent), interpersonal (e.g., clinical-patient gender differences) and system (e.g., lack of staff experience) using a 5-point Likert scale (“strongly agree,” “agree,” “neutral,” “disagree,” or “strongly disagree”).

Semi-structured interview

Interviews were used to supplement our quantitative findings, specifically to elicit deeper individual HCP perspectives on contraception counseling for adolescents. The guides (see appendix) included open-ended questions based on the TPB constructs.

For example, questions exploring attitudes included: “In general, how do providers at this clinic feel about talking about providing contraception to adolescent women?", “What do you think impacts adolescents’ decisions to use birth control?” and “In your opinion, what should be the role of healthcare providers be in reducing unintended pregnancy among adolescents and young adults?”. Questions on subjective norms included: “Who are the people or groups of people that influence your practice of care?”, “What is the role of your colleagues, supervisors, donors, and of the ministry of health or national guidelines?’’. Perceived behavioral control was explored with questions including: “In your opinion, what are the biggest challenges in discussing sexual health and pregnancy prevention with adolescent female patients?” and “In your opinion, what needs to change so that this clinic can better address the sexual health needs of adolescents?”.

Data analysis

For quantitative analysis, survey findings were translated from Haitian Creole back to English and descriptive statistics were used to present the categorical data as proportions. There were no missing data. All statistical calculations were conducted using SPSS, Version 20 or SAS software v 9.4 (SAS Institute, Cary, NC, USA).

For qualitative analysis, interview audio-recordings were transcribed and translated from Haitian Creole to English. We used an iterative process to identify emergent themes within and across interviews. Interview transcripts were uploaded into Dedoose software (Version 4.12) for analysis. A coding tree was developed based on the interview guides and periodically revised to include relevant inductive codes as emergent themes arose. The first three interviews were coded together by three members of the study team (Masonbrink, Hurley, Schuetz) to develop mutually agreed upon definitions for each code and to establish examples of each code. Codes were reviewed and revised, and the interviews were again coded by the same team members. Any disagreements in coding were resolved by consensus. Each interview was then coded separately by 1–2 members of the study team. Upon reaching thematic saturation, the three team members met to discuss the results; again, any disagreements in coding were resolved by consensus. Memos of coding decisions were kept to provide consistency in coding as the coding progressed. The coding team summarized coding outputs, synthesizing major themes according to TPB constructs.

Results

Quantitative findings

Demographics and clinical experience

Among our 58 respondents, a majority were female (n = 52, 90%), were either 30 to 39 (n = 19, 33%) or 40 to 49 (n = 25, 43%) years old and approximately half were nurses (n = 31, 53%) and 17% (n = 10) were medical doctors (Table 1). Most HCPs reported always (n = 16, 28%) or very often (n = 21, 36%) obtaining a sexual history when caring for adolescent patients. Most HCPs (n = 51, 88%) estimated <  = 10% of their adolescent patients have a health condition (e.g., diabetes mellitus, depression) that could cause pregnancy complications.

Table 1 Healthcare provider characteristics
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Attitudes

HCP attitudes about contraception provision for adolescents are described in Fig. 2. A majority of HCPs agreed or strongly agreed that clinicians should discuss pregnancy prevention (n = 54, 94%) and high-risk sexual behaviors (n = 52, 90%) with their adolescent patients. Similarly, most agreed or strongly agreed (n = 52, 90%) that clinicians should discuss condoms with their adolescent patients. A majority agreed or strongly agreed (n = 49, 84%) that personalized preventive counseling is effective in reducing high-risk sexual behaviors among adolescents.

Fig. 2
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HCP Attitudes about Contraception Provision for Adolescents

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Subjective norms

Most HCPs reported they consider informal (e.g., institution specific) guidelines (n = 25, 43%) or published guidelines from national medical organizations (n = 22, 38%) when providing reproductive care for adolescents.

Perceived behavioral control (barriers)

HCP perceived barriers to contraception provision for adolescents are described in Fig. 3. The most frequently cited provider-level barriers (i.e., significant or somewhat of a barrier) to contraceptive care for adolescents included insufficient knowledge about contraceptive management (n = 44, 77%), insufficient knowledge in how to talk to adolescents about pregnancy prevention (n = 43, 75%), and lack of sufficient time to personally provide care (n = 37, 64%). Patient-level barriers (i.e., rated as significant or somewhat of a barrier) included concerns that adolescents fear parents will be notified about sexual health behaviors (n = 37, 64%) and that adolescents give inaccurate information about their sexual behaviors (n = 25, 43%). System-level barriers included resistance to provide reproductive health services in the practice setting from ancillary staff (n = 40, 71%) and administration (n = 33, 57%).

Fig. 3
figure 3

HCP Perceived Barriers to Contraception Provision

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To decrease barriers, a majority reported they were “very interested” in further training regarding contraception management (n = 51, 88%), adolescent consent and confidentiality (n = 42, 72%) and taking a sexual history (n = 40, 69%). Given this further training, 49 (86%) reported they would be likely or extremely likely to increase provision of these services.

Qualitative interview findings

Seventeen HCPs participated in qualitative interviews with a mean age of 39.6 (standard deviation [SD]: 9.9) years and 11.3 (SD: 5.7) mean years of experience. Of these 10 were nurses, 3 were nurses aids, 2 were midwives, and 2 were lab technicians. Our qualitative findings commonly supported our quantitative findings, while also revealing additional factors. Table 2 summarizes themes and provides illustrative quotes related to each TPB construct (i.e., attitudes, subjective norms, perceived behavioral control) regarding barriers and facilitators to contraceptive care delivery for adolescents.

Table 2 Qualitative interview illustrative quotes
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Attitudes

In interviews, many HCPs named pregnancy as one of the biggest health issues facing adolescents in their community. For example, one nurse stated “I am concerned about the frequency in which young adolescent women are getting pregnant nowadays. They can’t provide for these babies since they can barely provide for themselves, and oftentimes those babies are often suffering from malnutrition” (nurse, age 32 years). A majority of HCPs reported they feel they play a vital role in providing adolescents contraception education. Many stated that they believe educating youth, and their parents, on contraception is important to prevent unintended pregnancy; for example, a nurse stated “Their (HCP’s) roles should be to educate adolescent women about sexual health and birth control, they also need to educate their parents about it” (nurse, age 29 years). A minority of HCPs felt that promoting abstinence was important in pregnancy prevention. HCPs were also supportive of LARC for their adolescent patients, for example one participant stated “I think these methods are the best because they last a long time, that means people won’t have to worry about that them for a long time…I haven’t administered the IUD yet, but I am very comfortable with the subdermal implant and my patients are very happy using it” (midwife, age 32 years).

Subjective norms

When asked “Who are the people or groups of people that influence your practice of care?”, HCPs most commonly stated their administrative or clinical leaders (i.e., supervisor, director, nurse in charge) influenced their practice of care. These participants further stated they felt their administration’s role was to keep everything running smoothly and ensure staff had adequate training.

Perceived behavioral control (barriers)

Similar to the survey findings, during interviews many HCPs noted concerns about maintaining privacy and confidentiality while providing contraceptive care for adolescents. HCPs acknowledged that discussions about pregnancy and contraception with adolescents are sensitive topics in part due to community judgment; for example one participant stated “It is a sensitive conversation because everyone has their own opinions about pregnancy, they tend to be judgmental about pregnancy among young adolescents” (nurse, age 44 years). Additionally, HCPs reported that adolescents lack sufficient education about birth control. One participant stated “I am concerned because clearly no work has been done really to educate adolescents about sexual health. If they were educated about sexual health, I am sure they would put their knowledge to use and have safer sex” (nurse, age unknown). HCPs also noted further concerns about adolescents’ misconceptions about contraception. For example, one nurse stated, “They think they are too young for using birth control, they also think it will destroy all their white blood cells if they aren’t sexually active” (nurse, age unknown). Interestingly some HCPs themselves reported misconceptions about certain contraception methods; for example, one stated “Personally I think they string [IUD] might attract bacteria and causes some infections” (nurse, age unknown).

An additional barrier included concerns about lack of parental support. For example, one participant stated “The biggest challenge is their parents, they don’t want you as a healthcare provider to talk to their kids about birth control, they think you are encouraging them to go and have sex” (nurse, age 28 years). HCPs also noted that peer opinion and experiences influence adolescents’ perceptions about contraception use; for example one participant stated “Their peers impact them a lot, if one within a group of friends is using birth control and encounter some issues, that one will tell the group how birth control in general is troublesome and the rest of them will more likely stay away from it without even trying it” (nurse aid, age 48).

Further, most HCPs stated that they are comfortable providing contraception counseling to adolescents and remarked they are knowledgeable to provide education on the types and side effects. This finding differed from our survey results as most HCPs noted concerns insufficient knowledge about contraceptive options, how to prescribe, and side effects as significant barriers.

To decrease barriers, many HCPs expressed the desire for further training regarding contraceptive care for adolescents, some also noted the need for training for health promoters or community health workers. Some noted the need for more contraception options and consistent supplies, saying “I think they need to have all the different types of birth control here so that young women have more choices, have them always available not running on shortage like we always do here” (nurse, age unknown). Additionally, HCPs noted the importance of providing contraceptive care in youth-friendly settings. For example, one HCP stated “I think they need to create a space specially to educate the adolescents about sexual health, because putting them in a space with adult patients that are probably the same age as their moms to discuss sexual health makes them uncomfortable” (nurse, age unknown).

Discussion

In this multi-site, mixed-methods study, we used the TPB framework to describe HCP perspectives on contraceptive care for adolescents in rural Haiti. A majority of HCPs shared concerns about unintended pregnancy and agreed they play an important role in pregnancy prevention and contraception provision for adolescents in their community. Despite international guidelines to provide sexual and reproductive health services for youth [11], more than one third of participants reported only sometimes or rarely obtaining a sexual history from their adolescent patients. While HCPs were supportive of contraceptive care for adolescents, we identified numerous actionable barriers to provision of this care.

Similar to past literature, in our study most HCPs expressed concerns about insufficient knowledge and time to provide this care [14, 25]. Interestingly, during interviews many HCPs reported they felt comfortable and knowledgeable to provide contraception for adolescents. This discrepancy may be in part related to social desirability bias that influenced answers during in-person interviews rather than anonymous self-reporting during the survey. However, in both surveys and interviews, a large majority of HCPs desired further training on contraceptive care for youth. HCPs noted concerns about liability, and parental, community and peer judgement as barriers to contraception provision, which has been previously described [26]. Importantly, this finding also aligns with results from a previously published study as many youth also endorsed concern about judgement by peers, parents and HCPs as a significant barrier to contraception [10]. Thus, community outreach and interventions to improve parental and community contraception knowledge and support could improve contraceptive care for adolescents [27, 28]. HCPs also reported concerns about privacy and adolescent patients giving inaccurate information about their sexual behaviors. Given these concerns, many HCPs reported interest in receiving further training on consent and confidentiality and many also endorsed the importance of contraception provision in youth-friendly settings. We recently published AYA perspectives on contraception in Haiti, those results similarly highlighted the need for a youth-friendly approach to contraceptive care [10].

HCPs reported their contraception clinical practice is influenced by national or informal guidelines as well as by their clinical leadership (i.e., supervisors, directors). However, HCPs also noted concerns about resistance from ancillary staff and administration to contraceptive care. Studies in similar settings have noted concerns about the impact of national policies limiting provision of contraception care for youth, particularly those who are unmarried [14]. Additionally, lack of support and resources from clinical administrative staff, is also a known barrier to contraceptive care, including certain methods (e.g., LARC) [29,30,31]. Further exploration is needed to better understand the influence of national policies as well as the perspectives and impact of clinical leadership and administration on contraception care for youth.

International guidelines support provision of patient-centered contraceptive care for youth, including LARC [11]. We found HCPs were supportive of offering LARC (ie., subdermal implant, intrauterine device [IUD]) for adolescents, however, many HCPs noted a lack of LARC training and supplies. Additionally, some HCPs reported misconceptions about IUD side effects. This finding aligns with our previously published study, as many youth also similarly reported misconceptions on contraception side effects, including IUDs [10]. Thus, future efforts to provide LARC training, resources, and supplies are needed to increase access to these highly effective contraception methods.

Our findings should be viewed in light of the following limitations. Our enrollment consisted of a convenience sample of HCPs and therefore may be at risk for sampling bias. Reasons for declination were not collected so we were unable to compare between those who participated and declined. We enrolled a relatively small sample size (n = 58) though we enrolled across two sites to increase generalizability. While our findings may not be generalizable to other HCPs or clinical settings in Haiti, the demographics (e.g., age, sex, years of experience) of our study participants are similar to other HCP studies in Haiti [32, 33]. Lastly, due to the sensitivity of the topic there is a risk of inaccurate reporting as well as social desirability bias especially during interviews. Our team attempted to mitigate this risk by working with trusted community members and ensuring private tablet-based data collection.

While HCPs support contraceptive care we revealed a number of actionable barriers to improve care for adolescents in rural Haiti. Efforts to increase HCP knowledge and training on contraceptive care for adolescents, as well as resources to offer all contraception methods, including LARC, are needed. Further, HCPs highlighted the importance of providing contraception counseling in private, youth-friendly accessible settings, as well as community and parental engagement to increase education and support for contraception for adolescents in Haiti. Given the high rates of unintended pregnancy among adolescents in Haiti largely due to high unmet contraception needs, efforts to improve contraception access in this population are critically needed.