Qualitative study on stigma as a barrier to emergency contraceptive pill use among university students in the Lango subregion, Uganda

Abstract

Objective

The aim of the current study was twofold: to understand the nature and extent of stigma and to learn the reasons behind the decision not to use emergency contraceptive pills among university students in the Lango subregion of Uganda.

Design

An exploratory qualitative study design.

Setting

The study was carried out among university students in Lango subregion of Uganda.

Participants

40 female university students across four universities.

Main outcome measures

Stigma.

Results

Participants (n=40) aged 19–26 exhibited generally positive attitudes towards emergency contraceptive pills, recognising them as empowering and essential. Stigma, however, emerged as a substantial barrier manifested in societal judgements and negative perceptions. Themes included the positive attitude towards emergency contraceptive pills, perceptions of peers and the general public, and perceptions of health service providers.

Conclusion

Stigma significantly impedes emergency contraceptive pill use among university students in the Lango subregion, Uganda. Positive attitudes towards the pills contrast with societal judgements and provider stigmatisation. Tailored interventions addressing knowledge gaps, societal perceptions and healthcare system challenges are crucial for improving emergency contraceptive pill acceptability and utilisation among university students.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• One of the study’s main strengths is that participants from a variety of sites and this arguably offered a mode of triangulation, improving the robustness of our results.

• The study’s results may be susceptible to social desirability bias.

• The sensitive nature of the topic may have prevented participants from sharing information.

• The generalisability of our results is constrained by the fact that the data were only collected in one region.

Background

The issue of reproductive health and family planning remains a critical concern in many societies around the world.¹ Emergency contraception is a contraceptive method that can be used to prevent pregnancy after unprotected intercourse.² Generally, emergency contraceptives can be categorised into two categories: emergency contraceptive pills and intrauterine contraceptive devices.³ The emergency contraceptive pills are further categorised into two categories: combined oral contraceptive pills and progesterone-only pills.⁴ Although introduced in 2001, overall uptake of Emergency Hormonal Contraception is low especially in low-income countries.⁵ Improved access through deregulation and pharmacy provision did not raise the prevalence of emergency contraceptive use as expected, accounting for only 1 in 10 users globally.⁶ Contraception methods, including emergency contraception, can help prevent unintended pregnancy.⁵ In Uganda, a country marked by a rich cultural tapestry, there exists a complex interplay of traditional values, societal norms and modern influences, all of which contribute to the dynamics surrounding sexual and reproductive health.

The emergency contraceptive pill, commonly referred to as the ‘morning-after pill’, is a hormonal contraceptive method designed to prevent pregnancy following sexual contact.⁷ It proves to be the optimal solution for averting unwanted pregnancies when administered within a specific time frame after unprotected sexual intercourse.⁷ According to the 2020 report from the WHO, emergency contraception can effectively prevent up to 95% of pregnancies if used within 5 days of the sexual encounter.⁸ Existing literature highlights stigma as a significant impediment to the utilisation of emergency contraception.⁵ This literature discerns various forms of stigma, encompassing enacted stigma, anticipated stigma and internalised stigma.^{9 10} Moreover, due to the prevailing perception that contraception primarily falls under a woman’s responsibility,¹¹ women face stigma when they forget to use contraceptive measures.⁴ A perspective article published by a British reproductive healthcare provider aligns with the idea that stigma contributes to the low uptake of emergency contraception.¹² It is crucial to note, however, that this evidence stems from providers, and there is a dearth of evidence from the patient perspective.⁵

As the discourse on reproductive health and family planning continues to evolve globally, the specific challenges faced by university students in accessing and using emergency contraceptive pills within of Uganda have garnered increased attention. While existing literature provides valuable insights into the broader context of reproductive health in Uganda,¹³ there is a noticeable gap in our understanding of the impact of stigma on the uptake of emergency contraceptive pills among university students. Also, the available literature on reproductive health in Uganda often touches on issues such as contraceptive knowledge, accessibility and cultural influences.¹⁴ However, the unique challenges faced by university students specifically related to stigma surrounding emergency contraceptive pill use, remain underexplored. There is a need for a focused examination of the sociocultural, institutional and interpersonal dimensions of stigma to comprehensively understand its role as a significant barrier within this context. Further, existing research tends to provide a broad overview of contraceptive use and reproductive health practices in Uganda without examining into the specific experiences of university students. The Lango subregion, characterised by its distinct cultural milieu, may present challenges that differ from those faced by the general population. Thus, a gap exists in the literature regarding the targeted exploration of the unique circumstances influencing emergency contraceptive pill use among university students in Uganda.

Despite their accessibility and effectiveness, the uptake of emergency contraceptive pills among university students in Uganda appears to be impeded by the pervasive influence of stigma. A survey conducted among 385 female university students in Kampala revealed that approximately 33% reported the use of emergency contraception.¹⁵ In this context, stigma refers to the negative social attitudes and judgements associated with the utilisation of emergency contraceptives, particularly among young adults pursuing higher education. The impact of this stigma extends beyond individual decision-making, shaping the overall reproductive health landscape of university students in the region. This study aimed to delve into the lived experiences of students in the Lango subregion concerning the use of emergency contraceptive pills. By exploring the sociocultural, institutional and interpersonal dimensions of stigma, the research sought to generate insights that could inform public health policies, educational programmes and community-based initiatives, ultimately contributing to the enhancement of reproductive health outcomes among university students.

Study design and settings

This descriptive exploratory study was conducted among university students in the Lango subregion of Uganda. Data were collected in September 2022 through face-to-face, in-depth interviews with a selected sample of female university students representing the four universities in the Lango subregion. The choice of these four universities—Lira University, Team University, All Saints University and Uganda Martyrs University—was purposive, aiming to ensure a comprehensive representation of students from diverse backgrounds, encompassing socioeconomic, tribal, rural, urban and religious diversity. The Lango subregion comprises nine districts: Alebtong, Amolatar, Apac, Dokolo, Kole, Lira, Oyam, Otuke and Kwania District.

Study participants

The study participants comprised undergraduate female students from both public and private universities in the Lango subregion. The selection of university students was based on their vulnerability to poor reproductive health.¹⁶ Despite the widespread awareness of contraception and diverse birth control methods among Ugandan women, research indicates variations in levels of contraceptive use and knowledge.¹⁷ Stigma might be linked to contraceptive use due to the influence of traditional, religious and cultural norms that discourage women, including female university students, from using modern contraceptives such as emergency contraceptive pills. Despite engaging in high-risk sexual behaviours, female university students exhibit low levels of modern contraceptive usage.¹⁸

The study employed the principle of saturation to determine the sample size. To ensure saturation, data were scrutinised at the end of each interview day, checking for the presence of codes or categories and the need for additional interviews. Information redundancy served as the criterion for establishing the sample size, ensuring that no new data were being gathered as interviews progressed. After 40 interviews, data collection ceased, as no novel information was emerging. Purposive sampling techniques were used to select participants, aiming to involve individuals with firsthand experience related to the investigated phenomenon. Specific criteria were applied, focusing on participants’ roles and interactions with university students seeking emergency contraceptive services. Inclusion criteria specified that participants needed to be undergraduates in Lango subregion universities engaging in recent sexual activity, excluding weekend students and expectant women. Efforts were made to minimise bias by ensuring diversity in years of study, faculties, marital status and religious affiliations. Various departments were approached to obtain a comprehensive range of perspectives. Throughout the study, transparency and reflexivity were maintained, with the researcher documenting personal biases and reflections on the sampling process. Regular debriefing sessions and discussions with a mentor or colleague were conducted to address and remain aware of potential biases in the research process.

Patients and public involvement

No patients or member of the public were involved in this study.

Study instruments

We developed an in-depth interview guide in English to collect data from participants (online supplemental file 1). The interview guide outlined a hybrid, semistructured narrative approach¹⁹ for conducting interviews. Prior to formal data collection, we pretested the guide with five participants to enhance consistency in the interview process. The questions included in the interview guide aimed to explore participants’ perceptions, beliefs and experiences related to emergency contraceptive pills within the university context. Examples of questions posed during the interviews were: ‘Can you share your perceptions and beliefs regarding emergency contraceptive pills?’ and ‘How do you think emergency contraceptive pills are viewed within the university community? The focus was on understanding stigma associated with the use of emergency contraceptive pills among university students. Questions investigated into identifying specific sources of stigma and exploring social, cultural or religious factors contributing to the stigma. Additionally, we sought to understand how university students generally perceive seeking or using emergency contraceptive pills. The interviews concentrated on key aspects, such as accessibility, the experience when accessing and the experience of using emergency contraceptive pills. Throughout the interviews, we used probes to clarify and expand responses, enabling a comprehensive exploration of participants’ experiences within the overall narrative.¹⁹

Procedure

Three research assistants, who are social scientists trained in qualitative studies and interview methods, underwent training on the research protocol and data collection approaches to carry out the study. Our efforts focused on establishing rapport through the management of expectations, addressing concerns, creating a positive initial impression, fostering a safe and comfortable environment, embracing moments of silence, gauging the participant’s level of engagement, being accommodating, minimising barriers between researchers and participants, and expressing genuine interest in the participant. Consent was obtained from the participants for the audio recording of the interviews, each lasting between 30 and 45 min. The lead researcher consistently met with the research assistants to review fieldwork experiences, discuss challenges, address new issues, share lessons learnt and explore the impact of the interviews.

Analysis

The transcribed interviews were evaluated using Riessman’s narrative thematic analysis.²⁰ This approach uses an inductive method with an emphasis on the text’s content rather than how it is said.²⁰ There are various steps in analysing text this way. First, we initially coded the interviews with the goal of capturing the key points from the participants’ stories. The team members reviewed emerging themes and patterns throughout a subset of transcripts while paying special attention to the distinctiveness of the complete stories that were told and the study’s objectives. The participants’ stories and the themes were then compared for parallels and differences. Next, we combined the ideas that emerged into the key story themes, and created a codebook to record and arrange the defined final themes into codes. To support data management, the codebook was used in the last step to code and examine all interview data using NVivo software. Any new themes or views that surfaced during this analytical phase were given extra consideration. In the ensuing analysis, the team members collaborated to review and critically reflect on interpretations and findings in order to make sure that the conclusions were based on the experiences of the participants.

Rigour

To ensure rigour and accuracy, we used research assistants who are social scientists with training in qualitative studies and interview methods. Two researchers independently read the transcripts and conducted the analysis of the data. The themes that arose from the analysis were constantly compared with the original transcript text, and the authors met regularly for debriefing. The themes were reviewed and debated until consensus was reached. The authors used the words of the participants as recorded in the interview transcripts.

Before each interview the investigators orally introduced the informed consent form to the participant, explaining with the study’s purpose, the interview process and the voluntary nature of participation. Furthermore, the participants were informed in greater detail about the study’s confidentiality, data usage, potential risks and benefits. After this introduction, each participant was asked to sign the consent form. The participants were compensated for their time and reimbursed for the cost of transportation. We ensured privacy and confidentiality by conducting interviews in private settings, using pseudonyms anonymous storage of data and password protection of entered data. Interviews were conducted in quiet, secluded rooms or areas where nobody from the institution might overhear or interfere with the conversation.

Results of the study

The sociodemographic information of the participants

The sociodemographic information of the study participants is shown in table 1. The results show that the age range of the participants was between 19 and 26 years old. Out of the 40 respondents, 27 were Christians, 33 were in a relationship, 23 had used emergency contraceptive pills, 5 had become pregnant and of these 5, 4 had an induced abortion.

Table 1.

The sociodemographic information of the participants

Variable	Total (N=40)
Age	Range:19–26
Relationship
Married	4
In relationship	33
Not in relationship	3
Pregnancy status
Ever been pregnant	5
Never been pregnant	35
Emergency contraceptive pill use
Had used emergency contraceptive pills	23
Had not had used contraceptive pills	17
Induced abortion
Yes	4
No	35
Retained the pregnancy	1
Religion
Christianity	27
Islam	13

Themes related to the study

The study explored the narratives of female university students in the Lango subregion, Uganda, shedding light on the complexities surrounding the access and use of emergency contraceptive pills. The qualitative analysis reveals three interconnected themes that encapsulate the participants’ experiences: (a) general positive attitude towards emergency contraceptive pills, (b) perceptions of peers and the general public and (c) perceptions of health service providers.

Theme 1: general positive attitude towards emergency contraceptive pills

While exploring the complex circumstances surrounding the use of emergency contraceptive pills among university students in the Lango subregion, Uganda, including both those who have used and those who have not used them, the participants’ narratives reveal a notable theme of generally positive attitudes towards emergency contraceptive pills. This positive sentiment is summarised in the following quotes:

If I realized that I would become pregnant as a result of unprotected sex, I would get the emergency contraceptive pill. I would ask the pill from a pharmacist or any colleague or expert, 'I can’t risk pregnancy; my parents would skin me alive.

I have not used them, but I believe emergency contraceptive pills are a crucial option for us. It’s like a safety net that we have, and it’s empowering to know that we can take charge of our reproductive health when needed.

Having emergency contraceptive pills available gives me a sense of control over my body and future. It’s reassuring to know that I can make decisions about my reproductive health and not be solely dependent on external factors

The prevailing sentiment of empowerment among the participants underscores their belief that emergency contraceptive pills function as a safety net, offering control over reproductive health. The participants regard these pills as a valuable resource, facilitating informed decisions about their bodies and reproductive futures. Additionally, the perception of these pills as a means to exercise autonomy and reduce dependency on external factors contributes to a proactive approach to reproductive health.

Theme 2: perceptions of peers and general public

Despite a general openness to the use of such pills, numerous participants expressed feelings of embarrassment or shame associated with obtaining them. Anecdotes shared by participants highlight a prevailing atmosphere of judgement and disdain linked to the utilisation of emergency contraceptive pills. Negative perceptions, originating from both peers and the broader community, were identified as substantial barriers. The apprehension of being stigmatised and labelled by social circles and peers acted as a deterrent, impeding students from seeking and using emergency contraceptive options. Within this overarching theme, two distinct aspects emerged: the stigma surrounding premarital sex and the perception of irresponsibility.

Concerning the stigma associated with premarital sex, the study underscores the adverse impact of such stigma as a substantial impediment to the utilisation of emergency contraceptive pills among university students. Participants conveyed a sense of shame, judgement and apprehension regarding potential social repercussions linked to engaging in premarital sex. This psychological and emotional burden contributed to a hesitancy in accessing reproductive health services, including emergency contraception. Illustrated by the provided excerpts, participants described instances of ill treatment attributable to their engagement in sexual activity before marriage.

I feel like there’s this unspoken judgment from fellow students and society members when it comes to premarital sex… the fear of being labeled or mistreated for our choices creates a barrier that keeps us from accessing the reproductive health services we need.

Imagine feeling like there’s a shadow of judgment over me because I had sex before marriage. It’s not just about what I did but worrying about what people will say. Because of this fear of being talked about or treated badly, many of us don't talk about our reproductive health needs. It’s sad that this fear stops many students from getting emergency contraceptive pills when they really need them.

While I understand the importance of emergency contraceptive pills, the fear of judgment from others sometimes makes it difficult to openly accept and use them.

Participants using emergency contraceptive pills in the study expressed apprehensions about being labelled as irresponsible and lacking in moral values when seeking emergency contraceptive pills, highlighting a significant barrier to utilisation among university students in the Lango subregion, Uganda. This perception contributes to a reluctance to access timely reproductive health services, showcasing the impact of societal judgements on their decision-making.

There’s this idea that if you need emergency contraception, you're not responsible enough to prevent unwanted pregnancies. It’s like people see it as a sign of moral failure, and that judgment stops me from seeking help.

The fear of being seen as irresponsible holds me back. Society expects us to be responsible with our bodies, but when you need the emergency pill, it’s like admitting you failed. That stigma is a heavy burden to carry.

Generally, I think people blame educated people who have excessive amounts of sex and act carelessly during sexual encounters.

The experience of married female university students was not so different from that of those who had premarital sex. For example:

There is an association between people that suggests someone has been negligent […]; there is a stigma attached to it […]; you weren't being careful, and now you need to make amends for your mistakes.

It is sad to note that the fear of being branded as irresponsible is preventing students from accessing crucial reproductive health services. This stigma presents a substantial obstacle to the promotion of responsible and well-informed choices regarding sexual health. Nevertheless, some participants expressed the belief that taking emergency contraceptive pills is an act of responsibility, challenging the notion that it is careless or irresponsible.

I believe I used it a couple of times, and that means I was quite responsible and went right away, so there was no dirt around.

Yeah, indeed […] After having sex, I became worried and went down with a friend to get an emergency contraceptive pill. I needed to act responsibly.

Theme 3: perceptions of health service providers

Participants using emergency contraceptive pills vividly conveyed instances of feeling stigmatised, judged and unfairly labelled as ‘bad girls’ during their interactions with healthcare professionals, experiences that significantly dissuaded them from seeking timely reproductive health services. The emotional intensity of their encounters is encapsulated in one participant’s reflection:

I felt deeply stigmatized and labeled when I sought emergency contraceptive pills; it was as if my actions were being weighed against moral standards, making the whole experience emotionally challenging.

I felt so ashamed when I asked the nurse for the emergency pill. She gave me this disapproving look, and I could sense her judgment. It’s like they think they know your whole story in that one moment, and it’s really discouraging.

The stereotypes from health providers are disheartening. They assume we are careless or promiscuous just because we need emergency contraception. It’s not fair, and it makes you hesitate before seeking help.

Furthermore, the result highlights the pivotal role played by the attitude of service providers as a substantial barrier to emergency contraceptive pill utilisation among female university students. Participants using emergency contraceptive pills recounted instances of unwelcoming attitudes from healthcare professionals, fostering an environment that actively discourages them from accessing timely reproductive health services. One participant aptly expressed this sentiment:

Encountering a dismissive attitude from nurses made seeking emergency contraceptive pills an unwelcome experience. It felt as though my reproductive health concerns were not taken seriously, ………….

There was this time when I went to the drug shop to get the emergency contraceptive pill, and although the nurse said nothing, the look on her face was that of “young girl, why waste yourself, why do this, you should not have done this, and the like.

You can sense the judgment in their tone. The service providers act like they're doing you a favor, and it makes you regret seeking help. If they had a more positive attitude, maybe more of us would feel comfortable getting the emergency pill.

Discussion

A noteworthy discovery is the generally positive attitude towards emergency contraceptive pills among university students in the Lango subregion. Respondents expressed an understanding of the importance of emergency contraceptive pills in preventing unintended pregnancies, indicating a broad recognition among students. This positive attitude is indicative of responsible and proactive behaviour, showcasing a willingness among the student population to take charge of their reproductive health and adopt preventive measures in the face of potential unplanned pregnancies. Additionally, this positive attitude could contribute to destigmatising contraception within the community, challenging societal norms and fostering a more open and supportive reproductive health environment. Our results mirror findings from other studies in similar settings.^{21 22}

Our findings highlight that female university students have reported experiencing societal pressure and judgement concerning premarital sexual activity. This suggests that stigma associated with engaging in sex before marriage is a significant factor discouraging the use of emergency contraceptive pills among this demographic. The fear of being labelled as promiscuous or facing negative social consequences may contribute to hesitancy in seeking and using emergency contraceptive pills. It is important to note that our analysis is centred on the reports and perceptions of university students rather than direct observations of provider actions and thoughts. Cultural and religious values are likely influential in shaping the stigma associated with premarital sex. Additionally, the recurring theme of irresponsibility in our study echoes concerns among university students about being perceived as irresponsible for engaging in premarital sex, a sentiment supported by previous studies.^{23 24} Our investigation underscores that stigma, particularly related to premarital sex and perceptions of irresponsibility, serves as a significant barrier to the use of emergency contraceptive pills among university students in the Lango subregion, Uganda. To effectively address these stigmas, a comprehensive approach is needed, encompassing education, community engagement, policy advocacy and the promotion of supportive peer networks.

Uncovered in our study is that health service providers in the Lango subregion tend to hold stigmatising beliefs and negative stereotypes about students seeking emergency contraceptive pills. Participants expressed feelings of shame linked to these services, attributing it to the judgemental attitudes of healthcare professionals. The attitude of service providers highlighted various behaviours when students sought emergency contraceptive pills, including dismissive behaviour, lack of empathy and judgemental remarks. The presence of stigma, fueled by negative perceptions and attitudes of health service providers, discourages students from accessing essential reproductive health services. Our study extends previous research that demonstrated how feelings of irresponsibility deterred women from using emergency contraceptive pills^{25 26}; we found these same concerns deterred university students in Uganda from using the emergency contraceptive pill. In agreement with our findings, prior studies in Ghana, Zambia and Senegal reported that service providers’ attitudes were a barrier to the use of emergency contraceptives.^{27 28} In line with results, a 2021 focus group study of adolescents’ views regarding contraception in Arkansas discovered that many adolescents felt ashamed or embarrassed to obtain contraception through the local health centres.²⁴ Our finding has implications not only for individual well-being but also for public health, as delayed or avoided contraceptive use can lead to unintended pregnancies and related health challenges. Efforts should focus on creating a more inclusive and student-friendly reproductive health service environment through the implementation of policies emphasising non-discrimination and the provision of confidential reproductive health services.

The study has notable strengths. It provides a comprehensive exploration of the sociocultural, institutional and interpersonal dimensions of stigma surrounding the use of emergency contraceptive pills among university students. The inclusion of participants from four universities in the Lango subregion ensures a diverse representation of students from various backgrounds, thereby enriching the findings. Additionally, the study employs a rigorous analysis using Riessman’s narrative thematic analysis, enhancing the credibility and reliability of the results. However, the study also exhibits certain limitations. First, the findings may be specific to the Lango subregion, and caution should be exercised when generalising them to other regions or populations. Second, there is a potential for participants to underreport sensitive information due to social desirability bias, which could impact the accuracy of the findings. Third, the study exclusively focuses on the perspectives of female university students, thereby excluding the views of male students. This limitation hinders the attainment of a more comprehensive understanding of the dynamics surrounding the use of emergency contraceptive pills.

Conclusion

Stigma significantly impedes emergency contraceptive pill use among university students in the Lango subregion, Uganda. Positive attitudes towards the pills contrast with societal judgements and provider stigmatisation. Tailored interventions addressing knowledge gaps, societal perceptions and healthcare system challenges are crucial for improving emergency contraceptive pill acceptability and utilisation among university students.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by Gulu University Research and Ethics Committee approved the current study (GUREC-2022-305). Participants gave informed consent to participate in the study before taking part.