Healthcare workers’ attitudes and factors affecting sexual and reproductive health services to adolescents in refugee settlements, western Uganda

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This need is even higher in refugee settlements. This study aimed to assess the healthcare workers’ attitudes and the factors affecting adolescent sexual and reproductive health care in the Nakivale, Kyaka II, and Rwamwanja refugee settlements. Methods This was a cross-sectional quantitative study in which health workers from public and private health facilities from three randomly selected refugee communities in western Uganda responded to a questionnaire. The questionnaire collected information on services provided, the attitudes towards each of the services and the factors that hindered the provision of these services. Binary logistic regression was done to assess the baseline characteristics associated with provision of these services using SPSS version 26. Results Of the 386 medical professionals enrolled, 194(50.3%) were females with a mean age of 30.9 years (SD = 6.9). The services that were most commonly offered were contraception counselling/provision (81.3%), HIV prevention/care (79.0%), sexually transmitted infections prevention (78.5%) and comprehensive sexuality education provision (75.1%). The least offered services were safe abortion care (40.9%) and harmful traditional practice prevention (39.9%). The good attitudes were highest towards comprehensive sexuality education and antenatal, intrapartum plus postnatal care while the bad attitudes were highest toward safe abortion care. Inadequate training, age, residence, education level, designation and type of facility had a significant association with offering of the different services (P < 0.05 for all at multivariate level of analysis). Conclusion More efforts are still required toward provision of safe abortion care and harmful traditional practices prevention. This will be achieved by providing training which will be vital in improving knowledge and attitude toward these services. The training should be more focused on the older professionals and non-councilors. Figures Figure 1 Introduction According to literature, adolescent sexual and reproductive health (SRH) care needs are rising in both low and middle-income countries ( 1 ). This need is even much increased in refugee settlements where it is thought that the adolescents in these settings have a high risk of suffering adverse outcomes if the sexual and reproductive health needs are not attended to adequately ( 2 ). With 1,252,470 refugees and asylum seekers now residing there, Uganda is the third refugee-hosting nation in the world after Ethiopia and Kenya ( 3 ). Girls under the age of 18 make up 27% of these refugee groups, and adolescents in Uganda confront significant SRH issues due to their lack of SRH awareness, early sexual maturation, and unsafe sexual activities ( 3 ). It is known that women and girls encounter numerous challenges in accessing SRH services. The barriers include: lack of knowledge on SRH, socio-cultural and religious beliefs and practices, poverty, stigmatization, and healthcare workers’ (HCWs) negative behaviors among others. Attitudes of healthcare workers potentially affect access to and utilization of SRH services by women and adolescents. Studies in Sub-Saharan Africa (SSA) indicate that healthcare workers’ negative behaviors discourage women from seeking antenatal care, and young people from attending clinics or follow-up visits ( 4 ). Lack of respect for adolescents’ privacy and confidentiality, and the ill treatment by healthcare workers were some of the reported negative behaviors that discouraged sexually active adolescents from seeking SRH services ( 5 , 6 ). Youth-friendly services, or those intended to increase young people's acceptance of the use of existing sexual and reproductive health services, have recently come under increasing pressure to be developed ( 7 ). Despite the fact that more health clinics now provide youth-specific therapies, studies have revealed that young people still predominantly ignore utilizing these programs ( 8 ). The way that healthcare providers interact with their clients has been highlighted as one of the main barriers keeping teenage people from seeking contraception or medical advice ( 9 ). In humanitarian circumstances, including vulnerable populations, international recommendations emphasize giving priority to the provision of SRH information and services ( 2 , 10 , 11 ). Adolescent girls continue to have poor understanding of and access to SRH services in humanitarian situations like the Nakivale settlement ( 4 ). A 2011 report from the Women's Refugee Commission and the UNHCR claims that girls in the Nakivale refugee camp reportedly begin having sex for money as early as age 10 and often do so without having access to any family planning measures ( 3 ). Despite Uganda's SRH policies for adolescents, health care professionals lack the necessary tools to give children and adolescents the information and services they need ( 12 ). Provision of sexual and reproductive health services has an important impact on the teenagers' standard of life ( 13 ). These services must be available, and staff qualities like competence, secrecy, and provider privacy, as well as attitudes, play a significant role in how often people use them ( 6 , 10 ). Settlements of refugees are highly susceptible to problems with sexual and reproductive health ( 2 ). An understanding of health care workers’ attitudes toward adolescent sexual and reproductive health in humanitarian settings could be helpful in designing appropriate intervention measures to improve adolescent sexual and reproductive health in the settlements. Methods Study design and setting The study was done in 3 randomly selected refugee settlements in western Uganda, specifically Nakivale, Kyaka II and Rwamwanja. All 3 settlements had one health centre IV and privately owned health care providers. Mostly, each health Centre IV had five doctors, five clinical officers, 15 nurses and 13 midwives. These health professionals were enrolled. Also health workers of the different cadres from the private facilities were enrolled into the study to obtain a full picture of adolescent sexual and reproductive health services. Sample size and sampling Kish and Leslie formula was used to identify the necessary minimum sample size. n = z 2 (pq)/e 2 . Since no quantitative study had been done in Uganda on the subject, 50% was used for the proportion. Therefore P = 0.5, q = 0.5, e = 0.05 and z = 1.96. On substituting, n = 385.1 = 386. Therefore, a minimum of 386 participants was required. All health workers that agreed to participate in the research were enrolled after signing an informed consent document until the sample size was attained. Data collection procedure In a private room, a pretested structured questionnaire was administered by the principal investigator or study assistant. The participant gave information on the sexual and reproductive services offered to the adolescents. The participants also responded to the questions relating to their attitude toward provision of each of the services. The questions relating to factors affecting provision of sexual and reproductive health services were also responded to. Data collection took place from August to October, 2023. Data collection tools and study variables. A pretested questionnaire was used to collect the data relevant for the study objectives. Content Validity Index (CVI), was used to assess for validity, and adjustments made. The sociodemographic characteristics of the healthcare provider (age, sex, tribe, religion, place of residence, level of education, and marital status) as well as the attitude of the healthcare provider (positive (supportive, understanding) or negative (judgmental, stigmatizing, abusive, stereotyping) were the independent variables. Factors connected to health facilities (availability of services and availability of staff) were the intervening variables. Provision of the SRH services was the dependent variable. Statistical analysis Information was summarized in excel and entered into SPSS version 26 for analysis. The proportion of health workers providing specific services was computed. The proportion of health workers with a specific attitude category was computed. The proportion of factors reported by health workers to affect provision of sexual and reproductive services to adolescents was computed. Bivariate analysis was done for the study participants’ characteristics against provision of specific adolescent sexual and reproductive health care services. Variables with p value below 0.2 at bivariate were re analyzed at multivariate using binary logistic regression to determine health worker related factors significantly affecting provision of sexual and reproductive health care services. P value less or equal to 0.05 was regarded as significant. Operational definitions In this study health care workers refered to a health professional working in the study area at the time of data collection and having certification to work in health service institutions in direct care of patients including provision of family planning or related reproductive health services. Offering comprehensive sexuality education, advice and supply of contraception, care during pregnancy, during labor, and after delivery, safe abortion procedures, preventing and treating sexually transmitted illnesses, treating HIV, prevention, management, and adjustment of harmful cultural practices in relation to violence against women and girls. Results In this study, no service was offered by all study participants. The service that was most commonly offered was contraception counselling and provision offered by 81.3% of the participants, followed by HIV prevention and care (79.0%), sexually transmitted infections prevention and care (78.5%) and comprehensive sexuality education provision (75.1%). The least offered services were safe abortion care offered by only 40.9% of the study participants and harmful traditional practices prevention offered by only 39.9% of the participants. The rest of the services offered are shown in Fig. 1 . The majority of the study participants had a good attitude regarding offering services for adolescent sexual and reproductive health as evidenced by their responses on the questions regarding attitude. Majority responded that “ adolescents need to be helped ” and “ adolescents need to be educated ”. The good attitudes were highest towards comprehensive sexuality education provision and antenatal, intrapartum and postnatal care with about 80% of the participants reporting that adolescents that need these services need to be helped and educated. The bad attitudes were highest toward safe abortion care with 21.8% of the participants reporting that “ they don’t want to help adolescents who need safe abortion care ”. The details of the attitudes are shown in Table 1 . Table 1 Attitudes of medical professionals regarding offering services for adolescent sexual and reproductive health in the refugee camps of Nakivale, Kyaka II, and Rwamwanja. Comprehensive sexuality education provision Contraception counselling & provision Antenatal, intrapartum and postnatal care Safe abortion care STI prevention and care HIV prevention and care Violence against females prevention and care Harmful traditional practices prevention Attitude Percentage of participants who checked response They are careless 19.4 19.9 17.4 29.5 23.8 19.9 16.3 14.0 They have no morals 21.8 22.3 17.4 31.6 20.7 17.6 14.8 17.1 They were poorly brought up 29.5 23.8 22.0 26.4 18.1 16.6 19.7 19.7 They will be punished by God 18.7 16.8 13.5 27.2 16.1 13.5 12.4 13.2 They are irresponsible 22.8 20.7 13.7 25.6 21.0 14.8 13.0 14.5 They are stupid 14.2 12.7 12.2 16.8 12.2 14.0 13.0 13.0 They need to be helped 79.0 71.2 80.8 60.9 76.9 75.6 76.4 74.1 They need to be educated 80.8 79.3 79.8 70.5 80.3 82.4 81.6 74.6 I don’t want to help them 13.2 15.5 14.0 21.8 14.0 16.1 16.1 13.7 Mistakes are part of Life 21.0 19.2 15.5 22.0 21.5 16.6 20.2 16.6 Others 1.6 2.3 1.8 1.8 2.6 1.8 1.0 1.0 The main factor that hindered delivery of adolescent sexual and reproductive health services that cut across all services was inadequate training with up to 62.7% of the participants reporting that they had inadequate training regarding harmful traditional practices prevention. Compared to other services, safe abortion care was more hindered by contradiction with beliefs of medical professionals reported by 32.6% of the study participants, contradiction with culture of medical professionals (31.6%), contradiction with faith/religion of medical professionals (43.8%) and fear of imprisonment (19.4%). Compared to other services, violence against women and girls prevention was more hindered by “other” factors which were not explored in this study (41.7%). The rest of the factors impacting the delivery of adolescent sexual and reproductive health services are shown in Table 2 . Table 2 Factors impacting the delivery of adolescent sexual and reproductive health services in the Nakivale, Kyaka II, and Rwamwanja refugee camps. Comprehensive sexuality education provision Contraception counselling & provision Antenatal, intrapartum and postnatal care Safe abortion care STI prevention and care HIV prevention and care Violence against females prevention and care Harmful traditional practices prevention Factor/reason Percentage of participants who checked response Inadequate training 55.4 41.2 42.7 40.7 42.0 39.9 41.7 62.7 Contradiction with my values 26.9 24.6 18.4 28.5 18.4 15.8 21.8 22.0 Contradiction with my beliefs 25.6 24.4 18.7 32.6 19.9 18.4 16.3 23.3 Contradiction with my culture 22.3 25.9 20.7 31.6 18.9 17.4 20.2 23.3 Contradiction with faith/religion 25.6 32.6 18.1 43.8 17.9 23.1 22.8 25.1 Services are not available 24.6 30.1 21.5 31.6 18.9 26.4 26.7 31.3 Services are expensive 26.7 25.9 37.0 28.0 28.2 27.7 23.6 21.2 No time to offer the services 17.4 11.1 8.3 8.0 7.3 9.3 16.1 15.3 I will be imprisoned 2.8 1.3 7.3 19.4 2.6 3.6 5.2 4.1 Others 2.8 5.4 4.4 3.1 5.7 7.0 41.7 4.4 Regarding the association between baseline characteristics and adolescent sexual and reproductive health services, age, residence, education level, designation of medical professional and type of health facility had a statistically significant association with offering of the different adolescent sexual and reproductive health services (P < 0.05 at multivariate level of analysis). Generally, increasing age of the medical professional was associated with less contraception counselling and provision. Rural residence was associated with increased provision of majority of the services except for HIV prevention and care. Being a nurse or doctor was associated with reduced provision of services as compared to being a counselor. Lower education level was associated with less contraception counselling and provision. Government facilities were more likely to offer adolescent sexual and reproductive health services compared to private facilities. The details of these associations are shown in supplementary file 1, tables S1-S8. Discussion This study was done to assess the healthcare professionals’ attitudes and behaviors in addition to the factors affecting adolescent sexual and reproductive health care in the Nakivale, Kyaka II, and Rwamwanja refugee settlements. The study enrolled 386 medical professionals, majority of whom were females with a mean age of 30.9 years (SD = 6.9). Majority were nurses, from private health facilities. The reason for having more nurses was because majority of the health workers in any health facility were nurses as it is with all health facilities in any part of the world. We noted that the service that was most commonly offered was contraception counselling and provision, followed by HIV prevention and care, sexually transmitted infections prevention and comprehensive sexuality education provision. The least offered services were safe abortion care and harmful traditional practices prevention. In agreement with our findings, a systematic analysis of the data on adolescent sexual and reproductive health services discovered that the majority of services offered in refugee populations focused on HIV/STIs and maternal and newborn health ( 14 ). The review found that services like female genital mutilation (FGM), safe abortion and post-abortion care were not commonly offered ( 14 ). The services like contraception counselling/provision, HIV prevention/care, sexually transmitted infections prevention and comprehensive sexuality education provision were part of the care packages for all patients irrespective of the age which can explain why they were the most commonly offered. The possible reason for low safe abortion care is the controversy that surrounds abortion in terms of the country laws as well as the beliefs and norms of the different communities. The low harmful traditional practices prevention services are most likely as a result of inadequate knowledge about the subject as seen in Table 2 . Contrally to our findings, a systematic analysis of the data on adolescent sexual and reproductive health services discovered that the majority of services offered in refugee populations focused on gender-based violence ( 14 ), yet in our study only about 53% of the respondents offered services relating to violence against women and girls. This low provision of such services could be because of low knowledge about the subject, however in Table 2 , about 41% of the participants reported that there were other challenges which affected these services that were not explored in this study. In this study, majority of the study participants had a good attitude regarding offering services for adolescent sexual and reproductive health. The good attitudes were highest towards comprehensive sexuality education provision and antenatal, intrapartum and postnatal care while the bad attitudes were highest toward safe abortion care. The fact that antenatal, intrapartum and postnatal care is part of routine care offered to all patients could have contributed to the good attitudes. In agreement with our findings, in a South African study, nurses said they had trouble understanding and implementing the notion of abortion ( 15 ). They clarified that their traditional ideas and values were in conflict with this practice, which resulted in a negative attitude toward the adolescents who came in need of this assistance ( 15 ) as was seen in this study (Table 2 ). Non-marital sex and its repercussions, such as pregnancy, abortion, and sexually transmitted illnesses, were noted to be viewed as immoral, disrespectful, and disobedient in Ghana ( 16 ), which is similar to many cultures in Uganda and across Africa. We also observed that the main factor that hindered delivery of adolescent sexual and reproductive health services that cut across was inadequate training. In agreement with our findings, lack of knowledge of SRH, was one of the main obstacles preventing the use of SRH in Ethiopia ( 5 ). Compared to other services, safe abortion care was more hindered by contradiction with beliefs of medical professionals, contradiction with culture, contradiction with faith/religion and fear of imprisonment. In agreement with this, negative cultural attitudes was one of the main barriers blocking young people in the Lao People's Democratic Republic from utilizing sexual and reproductive health services ( 17 ). Also a thorough investigation focusing on Africa reported that one of the main limiting factors was stigma ( 4 ). Increasing age of the medical professional was associated with less contraception counselling and provision which was in agreement with a study done in Nigeria where access to sexual and reproductive health care was shown to be substantially correlated with age ( 18 ). This may be because older people are more likely to have stronger beliefs in culture and tradition as compared to younger people. Rural residence was associated with increased provision of majority of the services except for HIV prevention and care. This was in agreement with findings by ( 5 ) in Ethiopia who reported that area of residence was substantially linked with the application of sexual and reproductive health services. This could be because in urban areas, patients are more likely to seek care from private facilities, which brings in the issue of costs as was seen in Congo, where Urban participants brought up costs as the hindrance to these services ( 19 ) Being a nurse or doctor was associated with reduced provision of services as compared to being a counselor. Also lower education level was associated with less contraception counselling and provision. In Nigeria access to sexual and reproductive health care was shown to be substantially correlated with education ( 18 ). This association could be arising as a result of knowledge about the subject. Counselors were more likely to offer these services possibly because they learn to understand every person and to avoid being judgmental which could have improved their attitude towards provision of these services. Government facilities were more likely to offer adolescent sexual and reproductive health services compared to private facilities. A thorough investigation focusing on Africa reported that one of the main limiting factor was cost ( 4 ). Since government facilities offer these services for free, it is understandable that they were more likely to offer these services. Also private facilities are aimed at maximizing profit which could explain why they would provide less of these services given that most of the adolescents may not have the funds to cater for these services even when they need them. This could be because they fear to get money from their parents or guardians for such services in fear of judgment or punishment. Strength and limitations This was the first multicentre study in Uganda that assessed the healthcare workers’ attitudes and factors affecting provision of sexual and reproductive health services to adolescents in refugee settlements of western Uganda. This was a cross sectional study in which conclusions about causation could not be made. Compared to other services, violence against women and girls prevention was more hindered by “other” factors which were not explored in this study. Conclusion The services that was most commonly offered were contraception counselling and provision, HIV prevention and care, sexually transmitted infections prevention and comprehensive sexuality education provision. The least offered services were safe abortion care and harmful traditional practices prevention. The good attitudes were highest towards comprehensive sexuality education provision and antenatal, intrapartum and postnatal care while the bad attitudes were highest toward safe abortion care. The main factor that hindered delivery of adolescent sexual and reproductive health services that cut across all services was inadequate training. Age, residence, education level, designation of medical professional and type of health facility had a statistically significant association with offering of the different adolescent sexual and reproductive health services. More efforts are still required toward provision of safe abortion care and harmful traditional practices prevention. Declarations Ethics approval and consent to participate The Directorate of Higher Degrees and Research and school of allied health sciences and the department of public health, Kampala International University Western-Campus, evaluated and approved the proposal. The study protocol was approved by Bishop Stuart University Research Ethics Committee (REC) accredited by Uganda National Council for Science and Technology (UNCST) with number BSU-REC-2023-203. Authorization for data collection in refugee camps was given by the Office of the Prime Minister, Uganda Refugee Department N o OPM41/1. all methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not Applicable Availability of data and materials Date is available and can be obtain by request to the corresponding author. Competing interests: The authors declare that they have no competing interests. Funding No applicable Authors’ contributions: SBM took a lead role in writing the proposal, submission and follow up for ethical review, data collection, data entry, and writing of the draft. UI and MML participated in the planning and supervision of the study. MGA, AA, IA, SAM, GNB and TSS were involved significantly in the analysis and writing of the manuscript. All authors read and approved the final manuscript. Acknowledgements: We acknowledge research participants, data collectors, and the settlement commandants for their kind cooperation and involvement in the study. We are grateful to the Research Team of Youth Alliance for Reproductive Health and Dr Franck Katembo Sikakulya for proofreading the manuscript References Abajobir AA, Seme A. Reproductive health knowledge and services utilization among rural adolescents in east Gojjam zone, Ethiopia: A community-based cross-sectional study. BMC Health Serv Res. 2014;14(1):1–11. Singh NS, Smith J, Aryasinghe S, Khosla R, Say L, Blanchet K. Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: A systematic review. PLoS One. 2018;13(7):1–19. Ivanova O, Rai M, Mlahagwa W, Tumuhairwe J, Bakuli A, Nyakato VN, et al. 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University Western Campus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tijjani","middleName":"Salihu","lastName":"Shinkafi","suffix":""},{"id":242500287,"identity":"0c2964f3-9c87-4337-848f-0442ef004731","order_by":8,"name":"Umar Ibrahim","email":"","orcid":"","institution":"Kampala International University Western Campus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Umar","middleName":"","lastName":"Ibrahim","suffix":""}],"badges":[],"createdAt":"2023-10-23 19:29:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3482989/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3482989/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":45375043,"identity":"0ae1ae7c-2f0e-445a-b18e-50156168204e","added_by":"auto","created_at":"2023-10-28 17:20:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65630,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdolescent sexual and reproductive health services offered by healthcare professionals in the refugee camps of Nakivale, Kyaka, and Kyangwali.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3482989/v1/8bcc115113c96e6350d6ed30.png"},{"id":54079699,"identity":"83a7ed61-47d5-49b6-8c43-00f24074111f","added_by":"auto","created_at":"2024-04-04 09:35:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":565997,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3482989/v1/571113b0-bb64-4df4-bb45-bb69f2b9d4dd.pdf"},{"id":45375044,"identity":"60f99512-8c7f-44af-adc1-2500b8613bc5","added_by":"auto","created_at":"2023-10-28 17:20:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":42533,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1073258.docx","url":"https://assets-eu.researchsquare.com/files/rs-3482989/v1/f98b183bf93b90cf8b7208f3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare workers’ attitudes and factors affecting sexual and reproductive health services to adolescents in refugee settlements, western Uganda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to literature, adolescent sexual and reproductive health (SRH) care needs are rising in both low and middle-income countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This need is even much increased in refugee settlements where it is thought that the adolescents in these settings have a high risk of suffering adverse outcomes if the sexual and reproductive health needs are not attended to adequately (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). With 1,252,470 refugees and asylum seekers now residing there, Uganda is the third refugee-hosting nation in the world after Ethiopia and Kenya (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Girls under the age of 18 make up 27% of these refugee groups, and adolescents in Uganda confront significant SRH issues due to their lack of SRH awareness, early sexual maturation, and unsafe sexual activities (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It is known that women and girls encounter numerous challenges in accessing SRH services. The barriers include: lack of knowledge on SRH, socio-cultural and religious beliefs and practices, poverty, stigmatization, and healthcare workers\u0026rsquo; (HCWs) negative behaviors among others. Attitudes of healthcare workers potentially affect access to and utilization of SRH services by women and adolescents. Studies in Sub-Saharan Africa (SSA) indicate that healthcare workers\u0026rsquo; negative behaviors discourage women from seeking antenatal care, and young people from attending clinics or follow-up visits (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLack of respect for adolescents\u0026rsquo; privacy and confidentiality, and the ill treatment by healthcare workers were some of the reported negative behaviors that discouraged sexually active adolescents from seeking SRH services (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Youth-friendly services, or those intended to increase young people's acceptance of the use of existing sexual and reproductive health services, have recently come under increasing pressure to be developed (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Despite the fact that more health clinics now provide youth-specific therapies, studies have revealed that young people still predominantly ignore utilizing these programs (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The way that healthcare providers interact with their clients has been highlighted as one of the main barriers keeping teenage people from seeking contraception or medical advice (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In humanitarian circumstances, including vulnerable populations, international recommendations emphasize giving priority to the provision of SRH information and services (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Adolescent girls continue to have poor understanding of and access to SRH services in humanitarian situations like the Nakivale settlement (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA 2011 report from the Women's Refugee Commission and the UNHCR claims that girls in the Nakivale refugee camp reportedly begin having sex for money as early as age 10 and often do so without having access to any family planning measures (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite Uganda's SRH policies for adolescents, health care professionals lack the necessary tools to give children and adolescents the information and services they need (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Provision of sexual and reproductive health services has an important impact on the teenagers' standard of life (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These services must be available, and staff qualities like competence, secrecy, and provider privacy, as well as attitudes, play a significant role in how often people use them (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Settlements of refugees are highly susceptible to problems with sexual and reproductive health (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). An understanding of health care workers\u0026rsquo; attitudes toward adolescent sexual and reproductive health in humanitarian settings could be helpful in designing appropriate intervention measures to improve adolescent sexual and reproductive health in the settlements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eStudy design and setting\u003c/strong\u003e \u003cp\u003eThe study was done in 3 randomly selected refugee settlements in western Uganda, specifically Nakivale, Kyaka II and Rwamwanja. All 3 settlements had one health centre IV and privately owned health care providers. Mostly, each health Centre IV had five doctors, five clinical officers, 15 nurses and 13 midwives. These health professionals were enrolled. Also health workers of the different cadres from the private facilities were enrolled into the study to obtain a full picture of adolescent sexual and reproductive health services.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSample size and sampling\u003c/strong\u003e \u003cp\u003eKish and Leslie formula was used to identify the necessary minimum sample size. n\u0026thinsp;=\u0026thinsp;z\u003csup\u003e2\u003c/sup\u003e(pq)/e\u003csup\u003e2\u003c/sup\u003e. Since no quantitative study had been done in Uganda on the subject, 50% was used for the proportion. Therefore P\u0026thinsp;=\u0026thinsp;0.5, q\u0026thinsp;=\u0026thinsp;0.5, e\u0026thinsp;=\u0026thinsp;0.05 and z\u0026thinsp;=\u0026thinsp;1.96. On substituting, n\u0026thinsp;=\u0026thinsp;385.1\u0026thinsp;=\u0026thinsp;386. Therefore, a minimum of 386 participants was required.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e All health workers that agreed to participate in the research were enrolled after signing an informed consent document until the sample size was attained.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData collection procedure\u003c/strong\u003e \u003cp\u003eIn a private room, a pretested structured questionnaire was administered by the principal investigator or study assistant. The participant gave information on the sexual and reproductive services offered to the adolescents. The participants also responded to the questions relating to their attitude toward provision of each of the services. The questions relating to factors affecting provision of sexual and reproductive health services were also responded to. Data collection took place from August to October, 2023.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection tools and study variables.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA pretested questionnaire was used to collect the data relevant for the study objectives. Content Validity Index (CVI), was used to assess for validity, and adjustments made. The sociodemographic characteristics of the healthcare provider (age, sex, tribe, religion, place of residence, level of education, and marital status) as well as the attitude of the healthcare provider (positive (supportive, understanding) or negative (judgmental, stigmatizing, abusive, stereotyping) were the independent variables. Factors connected to health facilities (availability of services and availability of staff) were the intervening variables. Provision of the SRH services was the dependent variable.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eInformation was summarized in excel and entered into SPSS version 26 for analysis. The proportion of health workers providing specific services was computed. The proportion of health workers with a specific attitude category was computed. The proportion of factors reported by health workers to affect provision of sexual and reproductive services to adolescents was computed. Bivariate analysis was done for the study participants\u0026rsquo; characteristics against provision of specific adolescent sexual and reproductive health care services. Variables with p value below 0.2 at bivariate were re analyzed at multivariate using binary logistic regression to determine health worker related factors significantly affecting provision of sexual and reproductive health care services. P value less or equal to 0.05 was regarded as significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eOperational definitions\u003c/h2\u003e \u003cp\u003eIn this study health care workers refered to a health professional working in the study area at the time of data collection and having certification to work in health service institutions in direct care of patients including provision of family planning or related reproductive health services. Offering comprehensive sexuality education, advice and supply of contraception, care during pregnancy, during labor, and after delivery, safe abortion procedures, preventing and treating sexually transmitted illnesses, treating HIV, prevention, management, and adjustment of harmful cultural practices in relation to violence against women and girls.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, no service was offered by all study participants. The service that was most commonly offered was contraception counselling and provision offered by 81.3% of the participants, followed by HIV prevention and care (79.0%), sexually transmitted infections prevention and care (78.5%) and comprehensive sexuality education provision (75.1%). The least offered services were safe abortion care offered by only 40.9% of the study participants and harmful traditional practices prevention offered by only 39.9% of the participants. The rest of the services offered are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe majority of the study participants had a good attitude regarding offering services for adolescent sexual and reproductive health as evidenced by their responses on the questions regarding attitude. Majority responded that \u0026ldquo;\u003cem\u003eadolescents need to be helped\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eadolescents need to be educated\u003c/em\u003e\u0026rdquo;. The good attitudes were highest towards comprehensive sexuality education provision and antenatal, intrapartum and postnatal care with about 80% of the participants reporting that adolescents that need these services need to be helped and educated. The bad attitudes were highest toward safe abortion care with 21.8% of the participants reporting that \u0026ldquo;\u003cem\u003ethey don\u0026rsquo;t want to help adolescents who need safe abortion care\u003c/em\u003e\u0026rdquo;. The details of the attitudes are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttitudes of medical professionals regarding offering services for adolescent sexual and reproductive health in the refugee camps of Nakivale, Kyaka II, and Rwamwanja.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive sexuality education provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContraception counselling \u0026amp; provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntenatal, intrapartum and postnatal care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSafe abortion care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSTI prevention and care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHIV prevention and care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eViolence against females prevention and care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHarmful traditional practices prevention\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAttitude\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePercentage of participants who checked response\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey are careless\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e29.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey have no morals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e31.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey were poorly brought up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e26.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey will be punished by God\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e27.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey are irresponsible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e25.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey are stupid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e16.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey need to be helped\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e79.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e71.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e80.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e60.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e76.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e75.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e76.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e74.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThey need to be educated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e80.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e79.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e79.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e70.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e80.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e82.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e81.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e74.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI don\u0026rsquo;t want to help them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e21.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMistakes are part of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e22.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe main factor that hindered delivery of adolescent sexual and reproductive health services that cut across all services was inadequate training with up to 62.7% of the participants reporting that they had inadequate training regarding harmful traditional practices prevention. Compared to other services, safe abortion care was more hindered by contradiction with beliefs of medical professionals reported by 32.6% of the study participants, contradiction with culture of medical professionals (31.6%), contradiction with faith/religion of medical professionals (43.8%) and fear of imprisonment (19.4%). Compared to other services, violence against women and girls prevention was more hindered by \u0026ldquo;other\u0026rdquo; factors which were not explored in this study (41.7%). The rest of the factors impacting the delivery of adolescent sexual and reproductive health services are shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors impacting the delivery of adolescent sexual and reproductive health services in the Nakivale, Kyaka II, and Rwamwanja refugee camps.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive sexuality education provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContraception counselling \u0026amp; provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntenatal, intrapartum and postnatal care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSafe abortion care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSTI prevention and care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHIV prevention and care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eViolence against females prevention and care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHarmful traditional practices prevention\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor/reason\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePercentage of participants who checked response\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e55.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e41.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e42.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e40.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e42.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e39.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e41.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e62.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContradiction with my values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContradiction with my beliefs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e32.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContradiction with my culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e31.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContradiction with faith/religion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e43.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e25.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eServices are not available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eServices are expensive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo time to offer the services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI will be imprisoned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e19.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e41.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the association between baseline characteristics and adolescent sexual and reproductive health services, age, residence, education level, designation of medical professional and type of health facility had a statistically significant association with offering of the different adolescent sexual and reproductive health services (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 at multivariate level of analysis). Generally, increasing age of the medical professional was associated with less contraception counselling and provision. Rural residence was associated with increased provision of majority of the services except for HIV prevention and care. Being a nurse or doctor was associated with reduced provision of services as compared to being a counselor. Lower education level was associated with less contraception counselling and provision. Government facilities were more likely to offer adolescent sexual and reproductive health services compared to private facilities. The details of these associations are shown in supplementary file 1, tables S1-S8.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was done to assess the healthcare professionals\u0026rsquo; attitudes and behaviors in addition to the factors affecting adolescent sexual and reproductive health care in the Nakivale, Kyaka II, and Rwamwanja refugee settlements. The study enrolled 386 medical professionals, majority of whom were females with a mean age of 30.9 years (SD\u0026thinsp;=\u0026thinsp;6.9). Majority were nurses, from private health facilities. The reason for having more nurses was because majority of the health workers in any health facility were nurses as it is with all health facilities in any part of the world.\u003c/p\u003e \u003cp\u003e We noted that the service that was most commonly offered was contraception counselling and provision, followed by HIV prevention and care, sexually transmitted infections prevention and comprehensive sexuality education provision. The least offered services were safe abortion care and harmful traditional practices prevention. In agreement with our findings, a systematic analysis of the data on adolescent sexual and reproductive health services discovered that the majority of services offered in refugee populations focused on HIV/STIs and maternal and newborn health (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The review found that services like female genital mutilation (FGM), safe abortion and post-abortion care were not commonly offered (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The services like contraception counselling/provision, HIV prevention/care, sexually transmitted infections prevention and comprehensive sexuality education provision were part of the care packages for all patients irrespective of the age which can explain why they were the most commonly offered. The possible reason for low safe abortion care is the controversy that surrounds abortion in terms of the country laws as well as the beliefs and norms of the different communities. The low harmful traditional practices prevention services are most likely as a result of inadequate knowledge about the subject as seen in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eContrally to our findings, a systematic analysis of the data on adolescent sexual and reproductive health services discovered that the majority of services offered in refugee populations focused on gender-based violence (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), yet in our study only about 53% of the respondents offered services relating to violence against women and girls. This low provision of such services could be because of low knowledge about the subject, however in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, about 41% of the participants reported that there were other challenges which affected these services that were not explored in this study.\u003c/p\u003e \u003cp\u003eIn this study, majority of the study participants had a good attitude regarding offering services for adolescent sexual and reproductive health. The good attitudes were highest towards comprehensive sexuality education provision and antenatal, intrapartum and postnatal care while the bad attitudes were highest toward safe abortion care. The fact that antenatal, intrapartum and postnatal care is part of routine care offered to all patients could have contributed to the good attitudes. In agreement with our findings, in a South African study, nurses said they had trouble understanding and implementing the notion of abortion (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). They clarified that their traditional ideas and values were in conflict with this practice, which resulted in a negative attitude toward the adolescents who came in need of this assistance (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) as was seen in this study (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Non-marital sex and its repercussions, such as pregnancy, abortion, and sexually transmitted illnesses, were noted to be viewed as immoral, disrespectful, and disobedient in Ghana (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), which is similar to many cultures in Uganda and across Africa.\u003c/p\u003e \u003cp\u003eWe also observed that the main factor that hindered delivery of adolescent sexual and reproductive health services that cut across was inadequate training. In agreement with our findings, lack of knowledge of SRH, was one of the main obstacles preventing the use of SRH in Ethiopia (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Compared to other services, safe abortion care was more hindered by contradiction with beliefs of medical professionals, contradiction with culture, contradiction with faith/religion and fear of imprisonment. In agreement with this, negative cultural attitudes was one of the main barriers blocking young people in the Lao People's Democratic Republic from utilizing sexual and reproductive health services (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Also a thorough investigation focusing on Africa reported that one of the main limiting factors was stigma (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIncreasing age of the medical professional was associated with less contraception counselling and provision which was in agreement with a study done in Nigeria where access to sexual and reproductive health care was shown to be substantially correlated with age (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This may be because older people are more likely to have stronger beliefs in culture and tradition as compared to younger people.\u003c/p\u003e \u003cp\u003eRural residence was associated with increased provision of majority of the services except for HIV prevention and care. This was in agreement with findings by (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) in Ethiopia who reported that area of residence was substantially linked with the application of sexual and reproductive health services. This could be because in urban areas, patients are more likely to seek care from private facilities, which brings in the issue of costs as was seen in Congo, where Urban participants brought up costs as the hindrance to these services (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBeing a nurse or doctor was associated with reduced provision of services as compared to being a counselor. Also lower education level was associated with less contraception counselling and provision. In Nigeria access to sexual and reproductive health care was shown to be substantially correlated with education (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This association could be arising as a result of knowledge about the subject. Counselors were more likely to offer these services possibly because they learn to understand every person and to avoid being judgmental which could have improved their attitude towards provision of these services.\u003c/p\u003e \u003cp\u003eGovernment facilities were more likely to offer adolescent sexual and reproductive health services compared to private facilities. A thorough investigation focusing on Africa reported that one of the main limiting factor was cost (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Since government facilities offer these services for free, it is understandable that they were more likely to offer these services. Also private facilities are aimed at maximizing profit which could explain why they would provide less of these services given that most of the adolescents may not have the funds to cater for these services even when they need them. This could be because they fear to get money from their parents or guardians for such services in fear of judgment or punishment.\u003c/p\u003e\n\u003ch3\u003eStrength and limitations\u003c/h3\u003e\n\u003cp\u003eThis was the first multicentre study in Uganda that assessed the healthcare workers\u0026rsquo; attitudes and factors affecting provision of sexual and reproductive health services to adolescents in refugee settlements of western Uganda.\u003c/p\u003e \u003cp\u003eThis was a cross sectional study in which conclusions about causation could not be made. Compared to other services, violence against women and girls prevention was more hindered by \u0026ldquo;other\u0026rdquo; factors which were not explored in this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe services that was most commonly offered were contraception counselling and provision, HIV prevention and care, sexually transmitted infections prevention and comprehensive sexuality education provision. The least offered services were safe abortion care and harmful traditional practices prevention. The good attitudes were highest towards comprehensive sexuality education provision and antenatal, intrapartum and postnatal care while the bad attitudes were highest toward safe abortion care. The main factor that hindered delivery of adolescent sexual and reproductive health services that cut across all services was inadequate training. Age, residence, education level, designation of medical professional and type of health facility had a statistically significant association with offering of the different adolescent sexual and reproductive health services. More efforts are still required toward provision of safe abortion care and harmful traditional practices prevention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Directorate of \u0026nbsp;Higher Degrees and Research and school of allied health sciences and the department of public health, Kampala International University Western-Campus, evaluated and approved the proposal. The study protocol was approved by Bishop Stuart University Research Ethics Committee (REC) accredited by Uganda National Council for Science and Technology (UNCST) with number BSU-REC-2023-203. Authorization for data collection in refugee camps was given by the Office of the Prime Minister, Uganda Refugee Department N\u003csup\u003eo\u003c/sup\u003eOPM41/1. all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDate is available and can be obtain by request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eSBM took a lead role in writing the proposal, submission and follow up for ethical review, data collection, data entry, and writing of the draft. UI and MML participated in the planning and supervision of the study. MGA, AA, IA, SAM, GNB and TSS were involved significantly in the analysis and writing of the manuscript. All authors read and approved the final manuscript.\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe acknowledge research participants, data collectors, and the settlement commandants for their kind cooperation and involvement in the study. We are grateful to the Research Team of Youth Alliance for Reproductive Health and Dr Franck Katembo Sikakulya for proofreading the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbajobir AA, Seme A. Reproductive health knowledge and services utilization among rural adolescents in east Gojjam zone, Ethiopia: A community-based cross-sectional study. BMC Health Serv Res. 2014;14(1):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eSingh NS, Smith J, Aryasinghe S, Khosla R, Say L, Blanchet K. Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: A systematic review. PLoS One. 2018;13(7):1\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eIvanova O, Rai M, Mlahagwa W, Tumuhairwe J, Bakuli A, Nyakato VN, et al. A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda. Reprod Health. 2019;16(1):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eIvanova O, Rai M, Kemigisha E. A systematic review of sexual and reproductive health knowledge, experiences and access to services among refugee, migrant and displaced girls and young women in Africa. Int J Environ Res Public Health. 2018;15(8):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eBirhanu Z, Tushune K, Jebena MG. Sexual and Reproductive Health Services Use, Perceptions, and Barriers among Young People in Southwest Oromia, Ethiopia. Ethiop J Health Sci. 2018;28(1):37\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eMazur A, Brindis CD, Decker MJ. Assessing youth-friendly sexual and reproductive health services: A systematic review. BMC Health Serv Res. 2018;18(1):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eWHO. Sexual Health and Its Linkages to Reproductive Health: An Operational Approach. 1st ed. World Health Organization. Geneva; 2017. 1\u0026ndash;12 p. \u003c/li\u003e\n\u003cli\u003eSalam RA, Faqqah A, Sajjad N, Lassi ZS, Das JK, Kaufman M, et al. Improving Adolescent Sexual and Reproductive Health: A Systematic Review of Potential Interventions. J Adolesc Heal. 2016;59(2):S11\u0026ndash;28. \u003c/li\u003e\n\u003cli\u003eChalla S, Manu A, Morhe E, Dalton VK, Loll D, Dozier J, et al. Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana. Women Heal. 2018;58(4):434\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eWHO. Recomandations of adolescents\u0026rsquo; SRHs [Internet]. WHO; 2018. 1\u0026ndash;64 p. Available from: https://apps.who.int/iris/bitstream/handle/10665/275374/9789241514606-eng.pdf\u003c/li\u003e\n\u003cli\u003eDesrosiers A, Betancourt T, Kergoat Y, Servilli C, Say L, Kobeissi L. A systematic review of sexual and reproductive health interventions for young people in humanitarian and lower-and-middle-income country settings. BMC Public Health. 2020;20(1):1\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003ePaul M, N\u0026auml;sstr\u0026ouml;m SB, Klingberg-Allvin M, Kiggundu C, Larsson EC. Healthcare providers balancing norms and practice: Challenges and opportunities in providing contraceptive counselling to young people in Uganda - a qualitative study. Glob Health Action. 2016;9(1). \u003c/li\u003e\n\u003cli\u003eEngel DMC, Paul M, Chalasani S, Gonsalves L, Ross DA, Chandra-Mouli V, et al. A Package of Sexual and Reproductive Health and Rights Interventions\u0026mdash;What Does It Mean for Adolescents? J Adolesc Heal [Internet]. 2019;65(6):S41\u0026ndash;50. Available from: https://doi.org/10.1016/j.jadohealth.2019.09.014\u003c/li\u003e\n\u003cli\u003eJennings L, George AS, Jacobs T, Blanchet K, Singh NS. A forgotten group during humanitarian crises: a systematic review of sexual and reproductive health interventions for young people including adolescents in humanitarian settings. Confl Health. 2019;13(1):15\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eJonas K, Crutzen R, Krumeich A, Roman N, Van Den Borne B, Reddy P. Healthcare workers\u0026rsquo; beliefs, motivations and behaviours affecting adequate provision of sexual and reproductive healthcare services to adolescents in Cape Town, South Africa: A qualitative study. BMC Health Serv Res. 2018;18(1):1\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eLoll D, Dozier JL, Zochowski MK, Boakye A. stigma. 2018;2(1):55\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eThongmixay S, Essink DR, De Greeuw T, Vongxay V, Sychareun V, Broerse JEW. Perceived barriers in accessing sexual and reproductive health services for youth in Lao People\u0026rsquo;s Democratic Republic. PLoS One. 2019;14(10):1\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eOdo AN, Samuel ES, Nwagu EN, Nnamani PO, Atama CS. Sexual and reproductive health services (SRHS) for adolescents in Enugu state, Nigeria: A mixed methods approach. BMC Health Serv Res. 2018;18(1):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eMbadu Muanda F, Gahungu NP, Wood F, Bertrand JT. Attitudes toward sexual and reproductive health among adolescents and young people in urban and rural DR Congo. Reprod Health. 2018;15(1):1\u0026ndash;14. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3482989/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3482989/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eAdolescent sexual and reproductive health care needs are rising in both low and middle-income countries. This need is even higher in refugee settlements. This study aimed to assess the healthcare workers\u0026rsquo; attitudes and the factors affecting adolescent sexual and reproductive health care in the Nakivale, Kyaka II, and Rwamwanja refugee settlements.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional quantitative study in which health workers from public and private health facilities from three randomly selected refugee communities in western Uganda responded to a questionnaire. The questionnaire collected information on services provided, the attitudes towards each of the services and the factors that hindered the provision of these services. Binary logistic regression was done to assess the baseline characteristics associated with provision of these services using SPSS version 26.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 386 medical professionals enrolled, 194(50.3%) were females with a mean age of 30.9 years (SD\u0026thinsp;=\u0026thinsp;6.9). The services that were most commonly offered were contraception counselling/provision (81.3%), HIV prevention/care (79.0%), sexually transmitted infections prevention (78.5%) and comprehensive sexuality education provision (75.1%). The least offered services were safe abortion care (40.9%) and harmful traditional practice prevention (39.9%). The good attitudes were highest towards comprehensive sexuality education and antenatal, intrapartum plus postnatal care while the bad attitudes were highest toward safe abortion care. Inadequate training, age, residence, education level, designation and type of facility had a significant association with offering of the different services (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all at multivariate level of analysis).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMore efforts are still required toward provision of safe abortion care and harmful traditional practices prevention. This will be achieved by providing training which will be vital in improving knowledge and attitude toward these services. The training should be more focused on the older professionals and non-councilors.\u003c/p\u003e","manuscriptTitle":"Healthcare workers’ attitudes and factors affecting sexual and reproductive health services to adolescents in refugee settlements, western Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-28 17:20:14","doi":"10.21203/rs.3.rs-3482989/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9e3eae0-d3d9-4eee-b5de-5c208e675f9d","owner":[],"postedDate":"October 28th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-04T09:27:24+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-28 17:20:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3482989","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3482989","identity":"rs-3482989","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}