An Enquiry into Attitudes of Female Students towards the Use of Injectable Contraceptives: The Case of Wits University. A research report submitted to the Faculty of Humanities, School of Human and Community development, Department of Social work, University of the Witwatersrand Johannesburg, in partial fulfillment of the requirements of the Degree of honors of social work By Cleopas Munemo Student number: 746286 Supervised by: Mr. Elvis Munatswa Year: 2017 UNIVERSITY OF THE WITWATERSRAND THE SCHOOL OF HUMAN AND COMMUNITY DEVELOPMENT SOCIAL WORK DEPARTMENT NAME OF STUDENT : Cleopas Munemo STUDENT NUMBER : 746286 NAME OF SUPERVISOR : MR Elvis Munatswa DECLARATION I Cleopas Munemo know and that plagiarism is wrong. Consequently, I declare that · Everything in the research report is my own work; · I have correctly acknowledged in the test all direct quotations and paraphrased ideas/ content. In addition, I have provided a completed reference list as required by APA method of referencing. · I understand that the University of the Witwatersrand may take disciplinary action against me if there is a belief that this is not my own aided work, or that I have failed to acknowledge the source of ideas/content in my text. Signed: __________________________________ Date: _____________________________ Abstract The emergence of injectable contraceptives provides women with multiple options to choose, among a wide variety of contraceptives methods. Although injectable contraceptives remain a viable alternative for a lot of females, contemporary studies demonstrate an increase in the use of injectable contraceptives by young adult females. In most cases, they are the least experienced in terms of sexual health and yet are under constant exposure during college years. The purpose of this study was to explore Wits student’s perceptions of injectable contraceptives and to establish their knowledge of and preferences among other contraceptive methods. The study adopted a qualitative approach to select participants for data collection and analysis. The study made use of one interview with a key informant. Again, the study made use of information gathered from a focus group consisting of five female participants only, that have used or are using injectable contraceptives. The study employed thematic analysis to analyse the collected raw data following the six-phase suggested by (Braun & Clarke, 2006). The information generated from this study helps us gain more insight on the issue of injectable contraception especially those that affect female university students. Acknowledgements This research project would not have been possible without the support of several people. I would like. to thank the following people for their direct and indirect contributions towards this research project: · Elvis Munatswa, for his time, effort, and patience during the course of this research project. I have learnt a lot from him through our interactions and from the feedback I have received regarding this project. I have enjoyed our conversations about the research. · Dr. Edmarie Pretorius, for time, effort, and knowledge, during the research lectures. I acquired profound knowledge which helped me during this research study. · Department of Social Work, the entire staff was supportive and more importantly their attitude was phenomenal, friendly, and eager to assist. Table of Contents CHAPTER ONE 4 Introduction 4 Contraception definition 5 Contraception in contemporary times 5 Contraception in South Africa 6 Contraception in Universities 6 Aim and rationale 7 Clinical Relevance 7 Social Relevance 7 Scientific Relevance 7 CHAPTER TWO LITERATURE REVIEW AND THEORETICAL FRAME WORK 8 The History of Birth Control and Evolution of Contraceptives 8 Early contraceptive use in Africa 10 Why Contraceptives? 10 Types of Contraceptives: Short Terms and Long-Term Contraceptives 11 The Effects of Contraceptives 13 Economic value of using contraception 14 The Choice Debate: Do Women Have Choice 15 CHAPTER THREE: METHODOLOGY 17 Research Approach and Design 17 Population and Sample 17 Research Instruments 18 Data Collection 19 Data Analysis 19 Phase 1: Familiarising Yourself with Data 19 Phase 2: Generating initial codes 20 Phase 3: Searching for Themes 20 Phase 4: Reviewing Themes 20 Phase 5: Defining and Naming Themes 20 Phase 6: Producing the Report 20 Ethical Considerations 21 Limitations 21 CHAPTER FOUR: ANALYSIS AND INTERPRETATION OF RESEARCH RESULTS 22 Introduction 22 Contraception decision making process 22 Factors influencing one’s chose 23 Medical eligibility 23 Cost 24 Convenience 24 Life style 26 Unprotected sex (skin to skin) 26 Use of injectable contraceptives 27 Frequency of use 27 Why use injectable contraceptives 28 Effectiveness 29 Expression of sexual liberty 29 Pleasure and gratifying sex 29 Once off uptake 30 Pros and Cons of Using Injectable Contraceptives 30 Advantages 31 Efficiency 31 Expression of Sexual liberty 31 Effectiveness period 31 Ease use 32 Disadvantages 32 Irregular period 32 Spotting 32 Headaches 33 Increased appetite 33 Stigma 33 Preferred methods 34 CHAPTER FIVE: SUMMARY AND CONCLUSION 35 Introduction 35 Review of the findings 35 Implication of the Study 36 Limitation of the study 36 For further study 37 References 38 Appendix A.: Participant Information Sheet (Focus Group & Key informant). 42 Appendix B. Consent Form for Participation in The Study (For FG & Key Informants). 44 Appendix C: Consent Form for Audio-Taping Recording of the Interview 45 Appendix D: Focus Group Discussion Guide 46 Appendix E: ethical clearance certificates 47 CHAPTER ONE Introduction The development and evolution of contraceptives had been remarkable in the past decades. One advantage of that is improved availability and access to contraceptives and one can strongly argue that it is an empowerment to women (Patrikar, Basannar, & Sharmac, 2014). Historically contraceptives were commonly used by married couples for family planning purposes. In recent the use of contraceptives has extended beyond the role of family planning as men and women used contraceptive for multiple other reasons (Snow, 2012). The influx in the use of contraceptives can be explained by the increase in women’s education a phenomenon that began in the 1960s. Again, the opening up of the labor market that previously marginalized women also have increased omen ability to access contraceptives (Bailey, 2006). This ascension should be not be mistaken to mean that all women have access to contraceptives (Mollmann, 2005). Although they are many studies that have been conducted in South African the use of contraceptives much of this literature does not indicate whether women and men are aware of the effects of the contraceptives they use on their health wellbeing. This study, hence, is an exploration of women awareness of the use of injectable contraceptive on health and wellbeing. The study seeks to understand how female students at Wits University perceive the use of injectable contraceptives among others. Before conducting this study, the study sort to understand female student’s perceptions of injectable contraceptives, their role, use and effects on their health and wellbeing. The aim was to understand whether young females, mainly college students who mostly are exposed to sexual networks are fully aware of the consequences of using injectable contraceptives among others. My study will therefore, contribute to knowledge and understanding of injectable contraceptives on health and well-being by responding to three questions that have not been answered in mainstream literature. Firstly, the understanding of the role and use of injectable contraceptives. Secondly their understanding, young females, mostly students understanding of the effects of the continuous use of injectable contraceptive among other on their health and 9wellbeing. Thirdly the study will explore whether young females understand the various contraceptive available before making a choice. Contraception definition According to (Kirch, 2008)Contraception or birth control refers to the deliberate act to prevent conception or impregnation by interfering with the normal process of ovulation, fertilization, and implantation. According to (Filshie & Guillebaud, 2013), each method has its own effects and risk and some methods are more reliable when compared to others. Although there are multiple forms of contraceptives available in South Africa, the most common include hormonal control, barrier methods, spermicides, intrauterine devices, tubal ligation, and vasectomy (Filshie & Guillebaud, 2013). According to (Charo, 2017), only abstinence is regarded as the safest method as it protects against unwanted pregnancy and disease infection. Contraception in contemporary times The revolution of contraception is an interesting story today there is a large variety of contraception. What is interesting is that many of these options they can perform more than one function (FengWang, 2013). Furthermore, (Rippe, 2013) argues different contraceptives allow women and men the liberty to choose any one which suits their lifestyle and health needs and income. According to (Hatcher & Nelson, 2007) technology had a direct impact on the evolution of contraception. (Hatcher & Nelson, 2007), further argues that the use of technology in this field is to improve existing birth control methods and develop new forms of birth control with the intention to improve women’s lives by reducing different health conditions which contribute to morbidity. Some of the modern contraceptives include the new hormonal implants and intrauterine devices, transdermal patches and vaginal rings (Sapkota & Soomro, 2015). It is also worth noting that the use of technology in the field of contraception is to establish low cost, easy to use, safe, and highly effective and develop contraceptives that have other health benefits other than preventing unintended pregnancy (Hatcher & Nelson, 2007). Although they are wide varieties of contraceptives that women can choose from when compared to the previous five decades, (Toebes, Ferguson, Markovic, & Nnamuch, 2014) argues that awareness and limited access to contraceptives have remained a huge problem in developing societies. Such a predicament can be explained by the following factors, poverty and lack of economic capital, poor/inadequate State policy and ignorance (Toebes, Ferguson, Markovic, & Nnamuch, 2014). Contraception in South Africa According to (UnitedNations, 2004) contraceptives in South Africa are mostly used to prevent unwanted pregnancies and family planning. According to the United Nations Population Fund (UNPPA), approximately 65% of women South Africa use some form contraception (UnitedNations, 2004) . This also explains a drop-in fertility rate from 2.92 children per women in 2001 to 2.35 children in 2011 (OECD, OECD Publishing). It is also worth highlighting that contraceptive use in South Africa is heavily influenced by one social and economic status and residence (Klausen, 2004). For example, (Klausen, 2004), argues that women living in poor socio-economic conditions and women in rural areas tend to have little or no knowledge of contraception and less access to contraceptives services. These factors are heavily associated with low contraceptive use. Education level has a significant impact on how contraceptive use among women (DepartmentofHealth, 2012). Therefore, the government and the private sector have made significant efforts to improve women’s level of education and this has yielded positive results (DepartmentofHealth, 2012). For example, contraceptive use among women who acquired post-high school qualifications is twice as high, 75%, when compared to women who do not have any educational 38%, (DepartmentofHealth, 2012). Although statistics indicate widespread use of contraceptives by men and women in South Africa, souring problems such as high abortion rates, sexually transmitted infections and teenage pregnancy, also show that South Africa remains in a crisis (Poku, 2017). In 2013 the department of health published statistics which indicated that were 89000 legal abortions which were conducted, and teenage pregnancy contributed to about 8% of all pregnancies, (DepartmentofHealth, 2012). Contraception in Universities The government of South Africa provide free contraceptives to most of tertiary institutions in the country through site clinics within institutions (Hodges, 2017). One example is the University of Witwatersrand, where students have access to free contraceptives administered by the Campus Health Clinic. The government perceives tertiary institutions as sexually active “centres” where young adults, most of who are unmarried and are inexperienced, tend to experiment with sexual encounters (Hodges, 2017). The government strives to provide free contraceptives to minimize unwanted pregnancy, to ensure students complete their studies without being disrupted by unintended pregnancies, to curb the spread of HIV and AIDS, to improve access to contraceptives and more importantly to improve the social and economic status of women especially the younger generation (Browner & Sargent, 2011). It is also important to note that unintended pregnancies among tertiary students, is still a problem, despite government’s and universities effort to persuade and encourage contraception use. Therefore, it means the government and universities must join forces, work together and devise new measures to tackle this problem otherwise the problem will persist. Aim and rationale The aim of this study was to understand how female students at Wits University, perceive of injectable contraceptives among other contraceptive method(s) and why. Clinical Relevance The study provides an understanding of the effects of continuous use of injectable contraceptives by young adults, specifically, female students in universities. Social Relevance The study provides insight into other alternatives to injectable contraceptives and their effects on health and wellbeing. Scientific Relevance The study also contributes to knowledge and understanding of the role and effects of injectable contraceptives among young adults, specifically young females in the university. 16 CHAPTER TWO LITERATURE REVIEW AND THEORETICAL FRAME WORK The History of Birth Control and Evolution of Contraceptives For as long men and women have been having children, there have been efforts to find measures to control family sizes. Artefacts dating back to ancient Greek society, suggest that contraceptives have been used for more than a thousand years in various parts of the worlds (McLaren, 1992). However, not every method was deemed effective and reliable (McLaren, 1992). In ancient Greece, (Riddle, 1992) the idea that family, and in turn the city-state would only effectively function if procreation was controlled was a widespread and common belief among the people. Therefore, (McLaren, 1992), believed that the Greeks sought to understand how fertility functioned to regulate it. To regulate birth control (Nelson, 2003), reported that in ancient Greece the following practices were encouraged homosexuality, coitus [sexual intercourse] interruptions commonly known as withdrawal, abstinence, anal sex, abortion, and exposure. Over time these practices proved not to be effective and reliable for instance coitus interruptions or withdrawal (Nelson, 2003). In addition, some methods often posed severe health risks on both men and women (Devettere, 2016). For instance, abortion often led to excessive bleeding, abdominal infection and death (McLaren, 1992). According to (Jütte, 2008), in their quest to find effective and moral techniques that would allow them to regulate fertility the Greeks believed that they were several herbal potions that had a contraceptive effect. For example, ‘Juniper berries’ were widely believed to contribute to temporary sterility when placed on the penis or vulva (Toebes, Ferguson, Markovic, & Nnamuch, 2014). Furthermore, a mixture of missy and water was believed to have a contraceptive effect and if a woman drank the mixture she would not become pregnant for a year. In addition, Aristotle is said to have argued that by anointing the womb with cedar oil, a woman could completely prevent her chances of pregnancy (Jutte, 2008). (McLaren, 1992), suppositories of peppermint and honey were believed to have had contraceptives effect as they dry out the uterus, therefore preventing pregnancy. (McLaren, 1992), highlighted that in ancient Rome birth control was also practiced despite attempts by the State to promote population growth. As (McLaren, 1992) mentioned in that era, the first concern of a Roman couple was to have children and surprisingly Roman families were small. This was due to their customary belief that emphasized equal division of inheritance of property among one’s children and therefore, having many children posed a threat to family stability. To add on that there was a point in Rome when one child was thought to be a burden especially to women since their health also depends on the numbers of children gives birth to (Jütte, 2008). To ensure that couples do not have too many children the following birth control practices were employed. Postpone or space birth and this was attained by abstaining from any sexual relations, (Jütte, 2008). The withdrawal was also practiced while women hold her breath, move away, sneeze immediately, squatting down and wipe the vagina all around, (McLaren, 1992). The great industrial revolution which began in the mid eightieth century had a profound impact on birth control and development and use of contraceptives (Brodie, 1997). Prior, Western societies, widely believed that population increase was a precursor for societal development (Allen, 2017). The industrial revolution brought with it wide spread poverty and structural inequalities as resources became concentrated on a few elite (Brodie, 1997). According to (Talwar, 2012), having a large family therefore, became a liability for many, particularly the unemployed and wage labourers. (Talwar, 2012), argues that scholars such as Malthus, emerged to explain that resource scarcity and overpopulation where a precursor for poverty and underdevelopment. In short overpopulation would exert pressure on scarce resources leading thereby ushering multiple forms of challenges. According to (Robertson, 2012), Malthus argued that poverty was a problem caused by the poor and it is the poor that should resolve that. According to (Martínez-Alier, 2003), this idea was later advanced by the Neo-Malthusianism who argued that smaller families had a greater chance of ameliorating poverty. During this period, modern methods of contraception were devised. For instance, the male condom, which was made from animal intestines and later developed using rubber sponge to absorb sperm (Jütte, 2008). In addition, the diaphragm, a small rubber device inserted into the vagina to shield sperm from the uterus, then it was made from acidic powders and jellies (Martínez-Alier, 2003). However, the question is how effective where these methods, (Allen, 2017), argues these methods had poor effective rate hence it was necessary to improve and devise new and effective methods. Early contraceptive use in Africa The use of contraception is Africa particularly in Sub-Saharan is argued by to have been because of rise of industrial revolution which took place in Europe (Robinson & Ross, 2007). According to (McDonald, 2012), industrial revolution resulted in imperialism which was the scramble for resources in Africa and colonialism. Prior to colonialism having big family with a lot of children within African tradition was perceived, culturally, socially and economically, to be a sign of success (Robinson & Ross, 2007). (McDonald, 2012), argues that with the rise of capitalism in Africa the discourse changed. Having many children began to be perceived as being regressive. Having many children began to be perceived and believed to be an invitation of poverty (Robinson & Ross, 2007). So, people were encouraged to have smaller families to avoid being in poverty. The use of contraception was then promoted and ever since sub-Saharan have strived to have contraceptives to ensure that have smaller families that they would manage economically (Klausen, 2004). Why Contraceptives? Although the primary use of contraceptive is to minimise the risk of unwanted pregnancy, empirical statistics demonstrate that women use contraceptives for several reasons (Bailey, 2006). (McLaren, 1992) , argues that in ancient Greece, the arrival of every new child was not always viewed as a blessing. In that society, (Jütte, 2008), argues that families were relatively small, and essential to the family was a male heir who would inherit family property. In addition, family wealth was not to be divided between too many claimants; hence, having many sons was also viewed as being cursed. To achieve this, women resorted to the use of contraceptive practices to prevent and terminate any unwanted pregnancy (Talwar, 2012). (Nelson, 2003), argues that women have always wanted absolute control over their fertility as another reason for contraceptive use. The quest to understand fertility and family relations, spurred a considerable debate as to who is responsible for procreation. In the past, women were perceived as passive actors in the process of procreation, particularly in male headed households (Talwar, 2012). This assertion created unbalanced power dynamics between men and women. In most societies, women’s roles were reduced to childbearing, with no bargaining power to negotiate or decide on the number of children. For example, in ancient Greek societies, women had little access to property and no absolute right own property hence a boy child was perceived to be more important than a girl child (Ridgeway, 2013) Religious and state policies undermined the agency of women with regards to birth control, (Beksinska, Smit, & Guidozzi, 2011). According (Beksinska, Smit, & Guidozzi, 2011), to the emergence of contraceptives provides women with opportunities to control their fertility. In recent years, women now have multiple options to prevent or terminate a pregnancy with/without the knowledge of their sexual partners (Charo, 2017). Since the advent of the Neo-Malthusian period, many women began to use contraceptives to ensure that they have smaller families and the rationale was few children would mean more economic resources which mean the mothers would be able to provide their children with good education (McLaren, 1992). Moreover, societal pressures and State policies are other reasons why women use contraception (Klausen, 2004). In some countries it is controversial because some policies tend to undermine the right of women with regards to their right to voluntarily control their fertility (Barr, 2010). For example, (Browner & Sargent, 2011) argued that in 1980 China introduced the one-child policy and all women forced to use contraception once they have had a child. Failure to follow the policy they were forcefully measures used to for women to take contraception, abort or their will experience severe punishment (Browner & Sargent, 2011). Types of Contraceptives: Short Terms and Long-Term Contraceptives The development and evolution of contraception have been remarkable since the ancient times today there are several methods of contraceptives available to both men and women (Bailey, 2006). According to (Bekaert & White, 2006), this allows women specially to choose preferred contraception which best suits their needs. In the history of contraception, women struggled to have effective and reliable contraception and these two factors that spearheaded the development and evolution of contraception (Bailey, 2006). Contraceptives can be in form of emergency, hormonal, long-acting and permanent contraception (Barr, 2010). At present contraceptives are categorized into long and short-term methods and they come in form of emergency, hormonal, barrier, long-acting and permanent contraception, (Hales, 2014). Short-term methods of contraception last no more than three months and some can use during or just after sex whereas long-term methods last for several years, (Hales, 2014). Hormonal contraception is one of the many birth control methods and it basically prevents pregnancy in two ways either by preventing fertilization process by thwarting the sperm from reaching or entering women egg or preventing the fertilized egg from implanting in the woman’s uterus and starting to grow, (Sabatini, Cagiano, & Rabe, 2011). There are several and different hormonal birth control methods and what differentiates them is the following three aspects type of hormone, for instance, oestrogen or progesterone; the amount of hormone and the way the hormone enters woman’s body, for example, they can be taken orally, implanted into body tissue, injected under the skin or inserted into a vagina, (Sabatini, Cagiano, & Rabe, 2011). Most common hormonal contraceptives are hormonal pills which are orally consumed over a period of three (Talwar, 2012). Depo-Provera, an injection you get from a nurse of a doctor once in three months (Talwar, 2012). Ortho-Evra, a patch which provides hormonal contraception through the skin, it is worn one for a week then replaced with a new one and it can be worn on the arm, abdomen, buttocks (Bekaert & White, 2006). Lastly the hormone vaginal ring, it is inserted in the vagina for a period of three weeks and removed on the first day of the fourth week when menstrual period begins, (Bekaert & White, 2006). Emergency contraceptive is another method of birth control it helps to prevent pregnancy by preventing or delaying the release of eggs from the ovaries when taken up to five days after unprotected sex (Bekaert & White, 2006). There are in form of IUD and pill, and the pills contain either progestin alone or a combination of progestin and oestrogen. The pill is the most common emergency contraception which is commonly also known as the morning-after pill (Bekaert & White, 2006). Barrier birth control method is another common and widely used form of contraception (Snow, 2012). Barrier methods of birth control they block the sperm from entering the uterus. According to (Mollmann, 2005), they differ from other methods on the basis that they are used only when you have sexual intercourse. The most common forms of barrier methods include diaphragms, cervical cap, male, and female condom, sponge, and spermicides (Rippe, 2013). Sterilization also forms as a form of birth control method it is best described as permanent contraception since it cannot be reversed, and it is extremely effective at preventing pregnancy when compared to other birth control methods (Hales, 2014). This type of birth control can be practiced by both men and women (Hales, 2014). Women undergo tubal ligation, a surgical process in which woman’s fallopian tubes are clamped and blocked to prevent eggs from reaching the uterus for implantation, (Bekaert & White, 2006). For men, vasectomy is performed, a surgical process in which male vas deferens responsible for transporting sperm are severed and tied to prevent sperm from entering the urethra, (Flores, 2015). Long-acting contraception is another form of birth control method, which includes the use of the intrauterine device a T-shaped device which is inserted into the uterus and the birth control implant a flexible rod about a size of a matchstick inserted under the skin in the upper arm, (Bekaert & White, 2006). The long-acting method is regarded as highly effective, easy to use and they have a lifespan which lasts for several years (Bekaert & White, 2006). The Effects of Contraceptives The idea to develop effective and reliable contraceptives was also driven by the idea to develop a wide range of contraception with little or no side effects and health risks. They have been a significant improvement in developing contraceptives with little or no side effects and health risks. According to (Sabatini, Cagiano, & Rabe, 2011), there are misconceptions and concerns about side effects of contraceptives and as a result, several studies that have been conducted to establish the possible side effects of different contraceptive based on the experiences of those using or have used birth control methods. Hormonal contraceptives, (Welling, 2013), are one of the most common methods of birth control in the world. (Sabatini, Cagiano, & Rabe, 2011), argue that studies conducted on the use of hormonal birth control methods report that hormonal contraceptives they do not pose serious sides effects. However common reported side effects include (Barr, 2010), weight gain, headaches, breast tenderness, breakthrough bleeding, irregular bleeding, mood changes, sexual effects, skins changes, and nausea. Barrier birth control methods are arguably some of the oldest forms of contraception the side effects of barrier birth control method depend on the method used as they are not the same. Condoms according to (Hatcher & Nelson, 2007), have minimum side effects since they are non-hormonal, they rarely cause medical problems, however latex sensitivity which may cause an allergic reaction is the common side effect reported. Spermicides according to (Ward & Hisley, 2015), have been reported to cause cervical irritation especially among women with acute cervicitis and frequent use may increase the risk of HIV. Diaphragm and cervical (Hatcher & Nelson, 2007), common side effect of these two methods is urinary vaginosis. Sterilization is regarded as one of the most effective birth control methods. Sterilization is argued to be side effects free. However, (Flores, 2015) argue that vasectomy, male sterilization has the following side effects, i) susceptible to cancer, ii) occasional swelling and pain, and IV) impotence or v) decreased sexual drive. (Hales, 2014) Noted the short-term side effects of vasectomy which include swelling, local pain, and discoloration. In extreme cases formation of blood clot, infection and inflammatory reaction might occur in small percentage cases, (Hales, 2014). Economic value of using contraception The use of contraception is perceived to have huge economic value. In a study conducted by (Sabatini, Cagiano, & Rabe, 2011), he examines the costs associated with the use of contraception. For 15 contraception methods, he analysed direct costs of obtaining and using the method, medical costs of resulting side effects and direct cost of unintended pregnancy (Sabatini, Cagiano, & Rabe, 2011). Although this model was specific to the United States, this model can also be used for other countries. To calculate the economic value of value contraception use, the outcome measure calculated for each method was the number of pregnancies avoided, which was defined as the difference between the number of pregnancies expected to occur if no method was used and the number of expected to occur with that method (Sabatini, Cagiano, & Rabe, 2011). However, the authors of the study concluded that regardless of the method contraception is highly cost-effective (Rippe, 2013). According to (Robertson, 2012), the economic value of contraception use is evident in how healthcare resources are saved by preventing unintended. Investing in contraception provide substantial economic savings and social benefits (Lord, 2010). In case of South Africa unintended pregnancy exerts a lot of pressure on the government budget (Klausen, 2004). It means the government should allocate more resource towards the child support grant, the health care facilities. For instance, when a teenage girl gets pregnant while she is studying, under the sponsorship of the government and decide to quit school, this means the resources that were allocated to this child have been wasted. This explains why the government strives to provide free contraceptives, it is a preventative measure which has huge benefits for all parties but mainly on the government side (Browner & Sargent, 2011). With more options to birth control, it benefits everyone and only the females. For instance, contraception allows the women to be better parents, couples with unintended pregnancies will likely experience depression and anxiety, while adults who plan tend to be happier (Charo, 2017). According to (Charo, 2017)Relationships tend to dissolve after unplanned pregnancy or birth. Those unplanned to be parents are more likely to develop a poor relationship. For university female students, unplanned and unintended pregnancies have drastic consequences, academically, economically, and socially (Lord, 2010). Hence at an institution like the University of Witwatersrand contraception is provided for free and easily accessible to students. At the start and during semesters several contraception awareness campaigns are carried out with the objective to encourage the use of contraception and minimise the risk of unintended pregnancies. The main message spread in those campaigns is that contraception use has more economic benefits to individuals that not using contraception at all. (Mdlankomo, 2012), in an interview with the Wits Campus health with Sister Maggy Moloi, she was reported that “Campus Health used to have a huge number of students seeking for assistance for abortion however those figures have dropped”. This might suggest that the accessibility of contraception to students has yielded the intended goal which is to prevent unintended pregnancies. The Choice Debate: Do Women Have Choice One of the issues that the feminist movements have been fighting for since the eightieth century to this day is to have voluntary fertility control. However, according to (Jütte, 2008), there is an ongoing debate on whether women have the freedom to make independent decisions regarding birth control and use of contraception. As mentioned by (Lord, 2010) It is generally concluded that the feminist movements have been successful in their bid to ensure women have the autonomy and liberty to make decisions, especially in the Western countries and other developed countries. Ever since access to adequate and safe contraception was made a basic human right by the United Nations and the customary international law to some degree women have been able to make independent decisions on whether to use or not contraception and to choose their preferred contraception, (Jütte, 2008). However, there are still factors that suppress the autonomy and liberty of women to make an independent decision to whether the use or not use contraception and choose their preferred contraception (Browner & Sargent, 2011). Such factors include government policies, race, religion and cultural practices and beliefs, patriarchy and availability issues (Browner & Sargent, 2011). All these factors deprive women their autonomy and liberty make independent decisions and most women who face these challenges are mostly from developing countries mainly in Africa (Browner & Sargent, 2011). The Roman Catholic Church is a perfect example of how religion deprives women to make an independent decision with liberty to choose whether to use contraception or not. According to (Devettere, 2016) the Church views and preach the use contraception as selfish and sinfully, therefore, it is morally wrong to use contraception. In 1968 Pope Paul VI published Official Roman Catholic teachings on contraception titled ‘Humanae Vitae' rejecting the finding of papal commission on contraception and stressing the idea that the use of contraception wrong, (Devettere, 2016). Government policies as mentioned in the above paragraphs are also other devised means put in place to undermine the autonomy of women to make independent decision to choose to use contraception or not. For instance, some countries such as the USA, for instance, have policies that require women obtain a prescription first to get contraception over the counter while other they coerce women to use contraception China for instance, (Browner & Sargent, 2011). In other countries, for example, Zimbabwe abortion is categorized as a criminal act, (Johnson, Ndhlovu, Farr, & Chipato, 2002). It is also these policies that contribute to the problem of availability, governments tend not prioritize women healthcare with regards to contraception. Governments justify the existence of these policies whilst these policies diminish the autonomy, liberty, and independence of women to choose whether to use or not use contraception. CHAPTER THREE: METHODOLOGY Research Approach and Design Conducting this study qualitative research design was employed. A qualitative approach was considered suitable for this study as it gives diverse strengths and logic to accomplish the objectives of the study. (Maxwell, 2013), described qualitative research as a research strategy which focuses on specific situations or people and emphasizes words rather than the quantification of in the collection and analysis of data. Also (Bryman, 2008), argued that as a strategy, it is inductive, epistemological (understanding of the social world through an examination of the interpretation of that world by its participants) and ontological meaning social properties are a result of interactions among individuals. Based on that, it was, therefore, useful in addressing exploratory questions. The qualitative approach was chosen for the following three reasons. Firstly, it facilitates the process of understanding meanings, situations, and accounts provided by lives and experiences (Maxwell, 2013). Hence this study was interested in how participants make sense of their world and how their understanding informs behavioural choices. Secondly, as highlighted by (Maxwell, 2013) the design facilitates the process of understanding the context within which the participant's act and the influence the context has on their actions. Thirdly, the design allows the researcher to understand the process by which events and actions take place, putting emphasis on the process rather than outcomes. The empirical form of data analysis which was used was thematic analysis. Population and Sample To attain the objectives of the study the sample of was drawn from the University of Witwatersrand. Selecting participants for this study purposive sampling technique was used. According to (Bryman, 2008), a purposive sampling technique is a non-probability sampling method and it involves purposefully identifying and selecting participants and they are chosen by the researcher. Purposive sampling was utilized in consideration of the nature of the research design, aims, and objectives of the study and the advantages of the technique. For example, purposive sampling was cost effective and time effective and given the sample size, five participants, it is an appropriate method when you intend to collect data from few participants. The criteria for sampling was primarily focused on a specific group from Wits University, registered female students who have either used or were currently using injectable contraceptives. This was necessary as it was significant that participants met the requirements for the research study. More importantly, the sampling of potential participants only began when the ethics committee approved the methodology of the study. To recruit participants posters were posted on all wits university noticed boards, advertising and inviting people to participate in the study. The poster had clear details specifying who can participate in the study, the aims of the study and the contacts of the researcher. The volunteers were also invited to contact the researcher to schedule an appointment. The sample was comprised of five university students that volunteered to participate in the research study. The participants were all female, of the five four once used injectable contraceptives and one was currently using injectable contraceptives. Seeking student was a quite a challenge considering that it was exam period hence most students were busy preparing for exams, however, five volunteers availed themselves. Research Instruments Focus group discussion was employed as the data collection tool for this research study. Focus group refers to (Bryman, 2008), a method of interviewing which involves more than one and at least four interviewees. According to (Bryman, 2008), focus groups have two distinct features firstly, they emphasize on specific theme or topic which is explored in depth, secondly, the accent is on interaction within the group and the joint construction of meaning. Focus group was best considered best suited for this study for the following four reasons. Firstly, it created an opportunity for participants to be interviewed in a relatively unstructured way about their experiences. Secondly, it allowed the researcher to develop an understanding of why they feel the way do as the method allowed participants to probe each other’s reasons for holding a certain view. Thirdly, it provided the also the researcher the opportunity to study the ways in which individuals collectively make sense of the phenomenon and construct meanings around it. Fourth, the researcher had a chance to get a more realistic response since it created a platform to argue forcing participants to think and revise their responses. The focus group discussion was held at one of the Wits University student residences in one of the participant room which was convenient for other participants and the discussion. Before the focus group was held the researcher presented each participant with an information sheet (attached as an appendix), obtained informed consent to participate and received permission to record the discussion (attached as an appendix). The focus group discussion was held on 31t h of October 2017. The discussion was forty minutes long and the discussion was then transcribed into a verbatim report. Data Collection Prior to conducting focus group discussion, the researcher conducted an interview with a key informant from Wits Campus Health Clinic. The key informant was a female nurse who had knowledge about injectable contraceptives and administers various kinds of contraceptives to wits Students. A single focus group discussion was conducted, since this was an academic research report, conducting more than one focus group would have been time-consuming since focus groups take too much time to arrange, transcribe the recordings and it will probably increase the complexity of data analysis Conducting the focus group discussion, a semi-structured approach was adopted using used nine general open-ended questions to guide the focus group session and the researcher played the role of a moderator and. To ensure free-flowing and open discussion in focus group interview some level of latitude was permitted to participants. The entire group discussion was audio recorded. Data Analysis Following data collection thematic analysis was used to analyse the raw data. Thematic analysis is best defined by (Braun & Clarke, 2006), as a process of analysing, identifying and reporting patterns of themes within collected data. This was chosen since it allowed the researcher to structure the findings, filter meaningful insights from the collected data and reach a conclusion. Using thematic I followed the six steps suggested by are (Braun & Clarke, 2006) to analyse the data. The following paragraphs will explain in detail each step. Phase 1: Familiarising Yourself with Data This stage involves the researcher immersing himself in the data to the extent that you are familiar with the depth and breadth of the content. To attain this the researcher first transcribed the data, read, and re-read the data in an active way, searching for patterns and meanings by taking and making notes. Phase 2: Generating initial codes This phase is whereby the researcher began to make initial codes (Braun & Clarke, 2006). To generate codes the researcher used a highlighter, highlighting interesting content and aspects which were directly linked to the objectives of the research study. Following that all coded content and aspect were copied and organized on a separate paper. Phase 3: Searching for Themes This phase focuses on refocusing the analysis at the broader level of themes rather than codes and it also involves sorting different codes into potential themes and collating all relevant coded data extracts within identified themes (Braun & Clarke, 2006). Therefore, the researcher used visual representations in searching for themes, mind maps and tables. This helpful as news themes were identified from other established themes. Phase 4: Reviewing Themes This stage involves the refinement of established themes. In refining the researcher used techniques, firstly, read all the collated extracts for each theme and this to check whether it is forming a coherent pattern (Braun & Clarke, 2006). A second technique which was employed is similar to the first one, but the only difference is that the researcher was checking the validity of each theme in relation to a data set. Phase 5: Defining and Naming Themes At this point the researcher defined and further refine the themes (Braun & Clarke, 2006). Coming up with the names of each theme the researcher first identified the essence of what each theme was about and determining what aspects data each theme captures. In doing the researcher deliberately attempted to identify what was interesting in the extracted codes and collated data. Phase 6: Producing the Report This phase is that last step in thematic data analysis. This stage involves the final analysis and writes up of the report and the main task here is to tell the story of the research study in such a way that the reader will be convinced of the merit and validity of the data analysis (Braun & Clarke, 2006). Ethical Considerations Ethics are essential to any research study; therefore, the researcher adhered to all ethical requirements of the HREC at the university. Confidentiality of all subjects was ensured; all transcriptions were stored in a safe place password protected device. To protect the identities of the participants in pseudonyms were used in place of their actual names. The focus group was conducted by the researcher after requesting and obtaining consent for participation, consent to audio record. The participants were informed before the interviews that they have the free will to withdraw from the research if they begin to feel uncomfortable to be part of the research. The researcher gave each participant researcher's and supervisor's contact details to provide them with an opportunity to voice any queries and view the project once it is completed. Limitations They were quite a few challenges experienced in this research study. Firstly, with the conducting focus group, it was challenging in recruiting participants given that most students were busy with preparing for examinations and transcribing was also time-consuming. Secondly, some potential participants declined to participate as expressed that there were not comfortable to share their individual experiences in a group. In accordance with general limits of qualitative methodology, it, therefore, means this research study has limited generalizability. The research used purposive sampling technique and all the people that volunteered who have either used and were currently using injectable contraceptives. That sample could differ from other have used and currently using injectable contraceptives but decided not to participate in the researcher study. Likewise, the perceptions of injectable contraceptives in other population groups are limited by the fact that the sample only consisted of black participants. CHAPTER FOUR: ANALYSIS AND INTERPRETATION OF RESEARCH RESULTS Introduction The previous chapter outlined the research methodology highlighting the instruments and data collection tools which were employed and more importantly the method of data analysis. Chapter four intend to investigate the essential meaning of the data which was obtained from the empirical study. The results and interpretation of the thematic analysis are reported in this chapter. During the data analysis phase several themes were identified within the transcripts. All themes are interconnected and built upon one another. Therefore, the themes are reported and structured in a way that the former theme introduces the latter themes. Themes that were identified are as follows, contraception decision making, Factors influencing one’s chose, use of injectable contraceptives, frequency of use, why use injectable contraceptives, pros and cons of using injectable contraceptives and preferred methods. Each of these themes will be introduced, evaluated, critically analysed and illustrated with quotes from the data collected. More importantly, pseudonyms have been employed to conceal the names of the participants of this research study. Contraception decision making process The evolution of contraceptives has been remarkable, today there is a variety of contraceptives that most women can choose from (DepartmentofHealth, 2012). Each method has its own pros and cons (Beksinska, Smit, & Guidozzi, 2011). The implication of this phenomenon is that when contemplating to use contraceptives is that it makes the decision process complex (Flores, 2015). It is important that you find a birth control method that suit your individual needs since there is a variety of methods. (Alexander, 2016), argues that deciding to use contraceptives is more than just selecting among attractive alternatives. (Alexander, 2016), suggest that when deciding one must have a strategy and compromises that satisfy personal, cultural and interpersonal needs which are mainly influenced by constrains, opportunities, values and norms. Therefore, if one requires a strategy when deciding does it then means there is some sort of a model that one has to follow when deciding which contraceptive method to use. If there is one is the model universal since women are not a homogeneous group. Even though there is a variety of contraceptives which provides women with multitude of options to choose from when they want to prevent pregnancy. (Sapkota & Soomro, 2015), there is no a clear defined model which one must follow when choosing which method to use there is variety of factors to consider(Reimold, 2010), argues there is no an answer to the question what factors determine contraception decision-making, contributing factors vary for different approaches When deciding on which contraceptive method to use it is clear from that collected data that there is no a clear-defined process or model Wits female students follow. For example, one participant mentioned that, “I only asked my friend who was using about the side effects she had experienced while using injectable contraceptives” (Nono, 2017, Interview. From then she went to the clinic and requested one. Another participant mentioned that, “I only contemplated about the consequences of getting pregnant and that was convincing enough for me to go seek contraceptives” (Kim, 2017, interview). Although there is a variety of contraceptives, it is important to establish a model which perhaps might be useful to women when choosing best and suitable method to use. Factors influencing one’s chose Medical eligibility The key factor, identified in this research study, which influence one’s chose especially among female Wits University students is the effectiveness of the method. The response of the participants proves that students are very much aware of the perils and consequences of unintended pregnancy. Therefore, to minimise the risks of getting pregnant they prefer to use a method which has the highest degree of effectiveness. This sentiment also shared by (Shoupe, 2011), who argues that medical eligibility is the only factor among many that women should consider when choosing a contraceptive method. Any method chosen if not effective it may lead to unintended pregnancy (Filshie & Guillebaud, 2013). During the focus group discussion all participants confirmed that they chose to use injectable contraceptives because they perceive them to be effective compared to other methods. According to (Bortolotti, 2010), injectable contraceptives have an effective rate of 99% while condoms effectiveness rate accounts to 85%. (Bortolotti, 2010), also argued that the risk posed by condoms is that they may tear off during sexual intercourse therefore, increasing the risk of getting pregnant. Based on the above figures injectable contraceptives may seem to more effective in comparison to other methods. However, it is worth noting that all form contraceptives are effective if used correctly and consistently (Hatcher & Nelson, 2007). (Beksinska, Smit, & Guidozzi, 2011), argues that medical eligibility is not the only factor women consider given that other contraceptives methods are effective if used correctly. There are also other factors which are equally important which need to be considered and cost of obtaining contraceptives is another important, (Filshie & Guillebaud, 2013). The following paragraphs will discuss how cost as a factor influences ones’ chose. Cost As mentioned in the above paragraph cost of obtaining contraceptives is one element which influences one choose on method to use. Cost was also another element identified during data analysis which influences decision of wits Female students when choosing contraceptive method. (Rippe, 2013), claims that although they are a variety of contraceptives some methods are relatively cheap while others are relatively expensive. Based on that (Rippe, 2013) argues that some women they do not have the buying power to buy expensive forms of contraceptives hence they end up using other methods initially they did not prefer. During the focus group discussion, Bongi said “I was tired of buying morning after pills” (Boning, 2017, interview) and Yaya said, “morning after pills are expensive” (Yaya, 2017, Interview). These statements clearly support (Rippe, 2013), claim, that some methods are expensive hence some women end using other method they afford but not their preferred methods. Given that these are students morning after pill is not sustainable form of contraception financially, hence they end up using injectable contraceptives. Morning after pills prices ranges between R60-R100. If Wits female student (those who are sexually active) engage in unprotected sex at least four times in a month. It means one must spare approximately R240-R400 to buy morning after pills. For students the idea is to engage in unprotected sexual intercourse with minimum or no money spent. Based on that I find out that Wits female students preferred to use injectable contraceptives for two reasons. Firstly, do not pose extra financial burden and secondly, they can easily access injectable contraceptive free of charge from Campus Health a university clinic. Convenience Convenience of the method is another factor identified from the research study which influences wits female students to choose injectable contraceptives. (Patrikar & D.R. Basannar), claim that ease of use is generally considered to be one of the most important aspect of the method. From the data analysis I found out that Injectable contraceptives they seem to be more convenient to a Wits female student considering their life style. For instance, Chichi said “I chose injectable contraceptive because if had chosen a pill it meant I was supposed to drink a pill every day for the entire month whereas injection I only get single shot in a period of three months” (Chichi, 2017, Interview). Nono another participant she also said, ‘I am too busy for pill”, (Nono, 2017, Interview). Therefore, this means method such condom, pills and emergence pills not the best options in terms convenience. The above statements support the idea that injectable contraceptives are convenient compared to other methods such as pills and condoms. For instance, pills they require one to drink a pill every day and drink it the same time you drank it the previous day. The inconvenience comes now in the form of having to keep track of time and making sure you drink one every day. The injection on the other hand, you just get a single shot which will last for three months and in that period, you are not required to do anything. Chances of forgetting to drink the pill among students is high considering their life style. (Mukherji, Ganguly, & Seal, 2016), if you forget to drink or miss the time, the danger is the suppression of ovulation may not occur, therefore, increasing the risk of becoming pregnant. Does this mean other contraceptives are not convenient and what is a convenient contraceptive method? (Patrikar, Basannar, & Sharmac, 2014), claims that, good convenience of contraceptives should be understood as method satisfaction, no fears of getting pregnant and ultimately no difficulty using the method appropriately. In this context wits female students perceive injectable contraceptives as convenient because they are easy to use, they can engage in unprotected sex with no uncertainties of getting pregnant. Least side effects Just like any other medical drug, contraceptives have side effects and some women do contemplate about the possible side effects of each birth control method they might want to use (Barr, 2010). According to (Hales, 2014), some women consult those that may have used contraceptives and health practitioners who administer contraceptives about possible side effects. From data analysis I also find out this is practice among wits female students. For example, Yaya mentioned that, “before I got my first injection, I asked my friends about their experiences with injectable contraceptives mainly the side effects, (Yaya, 2017, interview). According to (Beksinska, Smit, & Guidozzi, 2011), it is critical to know the side effects of each contraceptive method so that they can be recognized, prevented if possible and acted upon appropriately when they occur. More importantly having an idea of possible side effects based on experiences of others it allows you to self-evaluate if you will be to cope or not and that will also help to selecting the best method for you (Welling, 2013). The idea is to choose a method which has least side effects that you can cope with or that can be resolved easily, and which will not complicate one’s daily activities. Life style In above paragraphs life-style was also mentioned as one element which also determines which birth control method one will use. From this study I also found out that when choosing contraceptive method wits female students, life style is factor they also consider. (Shoupe, The Handbook of Contraception: A Guide for Practical Management, 2007), stressed the idea it is important to consider your lifestyle when choosing contraceptive method since it will have direct impact on the effectiveness of the method. According to (Turchik, 2010), there is high prevalence of risk sexual behaviour. Risk sexual behaviour is a common life-style among youngsters especially within tertiary institutions, Wits University is good example. According to (Reimold, 2010), risk sexual behaviour is best defined as any behaviour that increases one's risk of contracting sexually transmitted infections and experiencing unintended pregnancies. It involves, having sex at an early age, having multiple sexual partners, having sex while under the influence of alcohol or drugs, and unprotected sexual behaviours, (Reimold, 2010). During the focus discussion, one participant Kim said, “I decided not to use pills because I know myself, pills are likely not to be effective if drink any strong medication or alcohol beverages and when you get drunk chances of engaging in unprotected are high” (Kim, 2017, Interview). This statement suggests that when she decided to use injectable contraceptives she had carefully thought about her lifestyle. Therefore, of the available birth control methods, injectable contraceptives, Depo-Provera was the best suited for her lifestyle. (Snow, 2012), argues that the use of condoms requires one to have a consistent supply of condoms to ensure that each time they have sexual intercourse they wear one. (Snow, 2012), it is high unlikely for a female student to have condoms every time they engage in sex since carrying condoms is perceived to be responsibility of male partner. Therefore, in this context it perfectly makes sense for wits female student to use injectable contraceptives when consider their life style. Unprotected sex (skin to skin) To add on that all participants mentioned that one of the main reason they chose to use injectable contraceptives is to able to engage in skin to skin sexual intercourse. Interestingly they are conscious the consequences of skin to skin which is unprotected sexual intercourse which poses a high risk of getting pregnant. The decision to use injectable contraceptives is to then counter the risk of pregnant but still engage in skin to skin sexual intercourse which they feel is more pleasurable and satisfying. Another interesting revelation from the study is that they also chose to use injectable contraceptives because it allows women to get filled during sex. The term filled is an urban phase which means, male partner ejaculating in female reproductive organ, vagina, during sex. One participant for example mentioned the following, “I used to use pull-out method but it frustrating because it means when my boyfriend ejaculates he has pull-out to prevent pregnancy, I preferred him to ejaculate in my vagina and that is why now I use injectable contraceptives because he can ejaculate in me and no pregnancy” (Kim, 2017, Interview). Use of injectable contraceptives Injectable contraceptives are available in different forms, the three common types of injectable contraceptives are, Sayana Press, Depo-Provera and Noristerat, (Nagrath, Malhotra, & Shikha, 2012). The primary purpose of these three methods is prevent pregnancy. However, each one is used in a unique way. It is important to note that the participants informed the researcher that they were using Depo-Provera. Since they are all injectable, it is quite clear on how they are administered, they are administered as injection (Szarewski & Guillebaud, 2010). According to (Szarewski & Guillebaud, 2010), Depo- Provera contains progestin a natural hormone and it is administered by I.M injection of 150mg (Mayer, 2004). Depo-Provera is administered mostly by primary care health practitioners or doctors by injecting either upper part of arm or buttock. During the focus group discussion two participants confirmed that they got the injection in the upper arm while others got the injection at their buttock. On the other hand, Sayana Press is self-administered hence most women receive training to be able to self-inject themselves, (Mayer, 2004) however, not all clinics, hospitals and general practices currently offer this option in south Africa. Frequency of use According to (Filshie & Guillebaud, 2013) a single shot or injection of Depo-Provera is effective for 3 months. Therefore, if you want to prevent pregnancy, you must get one injection from your doctor which equals to four times in a calendar year, about 12 to 14 weeks separately (Flores, 2015). If you receive or get the injection in first seven days of your menstrual cycle, it works instantaneously. On the other hand, if you get the injection after your second week, it means you’ll need to use another form of birth control for a week at least (Filshie & Guillebaud, 2013). More importantly the health practitioner doctor will have to confirm if you are not pregnant before administering the injection (Hatcher & Nelson, 2007). Of the five participants, only one participant, Bongi used injectable contraceptive for more than a year. Bongi she reported that she is using, and she has been using Depo-Provera for the past three years. Chichi, one of the participant reported that she used Depo-Provera. Yaya, she used it three times while Nono and Kim used once. Only Bongi has been using the injectable contraceptives consistently for the past three years. This suggest that the method has been effective for her and it suit her life style despite the side effects that she experiences. According to (Sabatini, Cagiano, & Rabe, 2011), consistent is key for contraceptives to be effective hence she has not got pregnant thus far. Analysing the trend of frequent us of the other participants there is little consistent, Kim and Nono they used it once, Chichi used it twice and Yaya used it three times and stopped. More importantly of the five participants only Bongi was still using the injection method. The researcher results show that the irregular consistence use of the injection method among the participants is partly due to side effects they experience. Chichi during the discussion mentioned the following “I stopped because it was bad on my body”, (Chichi, 2017, Interview), Yaya also mentioned that “I quite after using it on three separate occasions because of the side effects I experienced”, (Yaya, 2017, interview). Despite the side effects they have experienced some of the participants informed the researcher would consider using injectable contraceptives again. Why use injectable contraceptives Just like any other drug all contraceptives have shortcomings and poses a certain amount of risks. Therefore, why one decides to use contraceptives in this context injectable contraceptives. One of the objectives of this research study was, to figure out why Wits Female University students use injectable contraceptives. The following paragraphs will detail all the reasons brought forward by the participants. Effectiveness One of the main reason that was brought forward buy the participants is the efficacy of injectable contraceptives. (Westhoff, 2003), states that injectable contraceptives, Depo-Provera has an effectiveness rate of 99%. However, it is only effective when used correctly and consistently (Hales, 2014). Based on figures 99% gives many students the confidence that if they used injectable the chances of getting pregnant are little or none existent. Bongi is great example, she highlighted that she has been using injectable contraceptives consistently for the past three years and in that time, she never got pregnant hence she is still using injectable contraceptives Expression of sexual liberty Besides the efficacy of injectable contraceptives. Injectable contraceptives allow one to express to their sexual liberty. According to (Mancini, 2010), sex liberty is concept unpinned in the broader ideology of sexual liberalism, which refers to a position that allows individuals, to engage in, without any judgement from others, their desired sexual practices. During the focus discussion, all the participants echoed the idea that injectable contraceptives allows them to have skin to skin (unprotected sex) sexual intercourse. For example, Nono mentioned that “sometimes you just want skin to skin” and Chichi also said “skin to skin is nice”. Pleasure and gratifying sex According to (Bailey, 2006), traditionally, sexual active youth were encouraged to protection while having sex to prevent pregnancy and spread of HIV/AIDS. This idea seems to have been dumped because of the sexual revolution which promotes sexual freedom, (Bailey, 2006). During the discussion, one participant, Yaya mentioned the following “we are not really concerned about protecting ourselves from diseases such as HIV/AIDS, but our primary gaol to have pleasurable and gratifying sexual intercourse and prevent pregnancy ultimately, hence we like to use injectable contraceptives, (Yaya, 2017, interview). The fact that most youth are less concerned about protecting oneself from venereal diseases is a huge concern and it is important to find out why. According to (Emans & Laufer, 2012) some youth are less concerned about contracting venereal diseases and using protection for two reasons. Firstly, unintended pregnancy has instant consequences compared venereal diseases Secondly, pregnancy can be seen therefore, it might bring out a sense of shame unlike some venereal diseases you cannot see them to (Emans & Laufer, 2012). In this study I also find out that wits female students they like their partners to ejaculate in than pull-out. Although pull-out method is another contraceptive practice, to some women it is not any option (Rippe, 2013). For example, Kim she mentioned that “pull-out method is frustrating” (Kim, 2017, interview) and Bongi said “she wants to be filled” (Bongi, 2017, Interview) meaning while having sex they prefer their partner to ejaculate in their vaginas. Therefore, the use of injectable contraceptives permits that. In one study, (Gordon, GallupRebecca, & Platek, 2002), in their quest to find out whether semen have antidepressant properties, or they reported that women who had regular unprotected sex enjoyed much lower rates of depression than women who had protected sex, even when frequency of sex was controlled for. (Gordon, GallupRebecca, & Platek, 2002) This may suggest that semen's antidepressant components have a positive effect on females' psychology, or perhaps it's just that women who often have unprotected sex are generally happier for another reason. Once off uptake From data analysis I also found out that Injectable contraceptives are administered easily when compared to other methods such as the implant. This was another reason given by the participants on why they particularly use injectable contraceptives. Injectable contraceptives you take them once in three months in form of a single shot injection unlike other methods. Participants, informed the researcher that they would have choose implant but there not comfortable about the process of obtaining the method. Firstly, the idea that a chip would be inserted in their body was not so welcome. Secondly, they opted against implant because of an article which was published in Wits Vuvuzela in 2016. Yaya, who read the article mentioned that article reported that number of student they wanted it removed because of side effects people were experiencing and some experienced technical problems while trying to get it removed. This make it is quite clear why they opted for injectable contraceptives compared to other methods. Pros and Cons of Using Injectable Contraceptives One of the main objectives of this research was to find out the advantages and disadvantages of using injectable contraceptives among females Wits University students based on their individual experiences. During the focus group discussion, the participants revealed several disadvantages and advantages of using injectable contraceptives. The following paragraphs will discuss both advantage and disadvantages of using injectable contraceptives Depo-Provera. Advantages Efficiency One advantage which was common to all participant is the medical eligibility mean the effectiveness and efficacy of the method. Depo-Provera has effectiveness rate of 99% which means if used correctly and consistently the risk of getting pregnant after having unprotected sex is extremely little (Westhoff, 2003). In this paper we have discussed reason why student use contraception and the main reason was clearly defined as to avoid getting pregnant. The wits Campus health clinic offers a variety of contraceptives to students in that context injectable seems to be the best option based on the ground of medical eligibility when compared to other methods such as condom and pills. Expression of Sexual liberty Another advantage of using injectable contraceptives, Depo-Provera, it allows all for skin to skin sexual intercourse and allows the male partner to ejaculate in the female, vagina without any worries of getting of pregnant. This speaks to the idea of sexual freedom discussed in the above paragraphs. One participant, Bongi, during the focus group discussion she mentioned that “one of the reasons why use injectable contraceptives is because condom hurts while having sexual intercourse”. Therefore, the idea is skin to skin is comfortable and makes the sexual intercourse more pleasurable. Effectiveness period A single shot of Depo-Provera is effective for three months (Barr, 2010). The length or the period is another advantage of using injectable contraceptives which was shared by the participants. For example, Nono mentioned that “what if I want to get pregnant next year so if use the implant which last for fives it means I have to wait for five years”. Based on that statement it means injectable contraception in this context, depo-prover allows one to make relatively short and long-term planning when compared to other methods. Ease use Above all injectable contraceptives seem to be best suited for students with regards to their life, which is another advantage of using injectable contraceptives. For instance, during the focus group discussion, one participant, Nono mentioned that “I am too busy for a pill”. That statement it clearly illustrates how injectable contraceptives are advantageous when compared to pills. Pills requires one to keep track of time that are supposed to drink the pill at a daily base. As for morning after pills, Yaya mentioned that they are expensive, given that they are students and they do not work. So why buy contraceptives when you have access to Depo-Provera offered by the university clinic, Campus Health, for free. Disadvantages Irregular period Irregular period is a common experience all the participants highlighted as a disadvantage of using injectable contraceptives. Irregular period refers to (Bland & Rowold, 2016), menstrual bleeding which occurs more occurs more frequently than every 21 days, lasts longer than 8 days, missed, early, or late periods. However, (Darrach & Darragh, 2013) argues that irregular period is not really a health concern except when you have consistently irregular periods and when you are pregnant. The question is, how then is irregular period a concern in the context of the participant. One participant Nono, informed the researcher during the focus “when you have irregular period and bleeding it means you have to wear a pad and pad is not comfortable it is hot”. To add on that she also mentioned that, “when you bleed it defeat the purpose of taking contraceptives because it prevents something from happening”. Analysing this statement, it may possibly mean if you bleed you will not able be able to have sexual intercourse in this case, skin to skin, therefore the defeating of main the purpose. Spotting The problem of bleeding is also accompanied by another problem mentioned by the participants which is spotting. Spotting defined as any light vaginal bleeding (droplets of blood) which happens any time other than when menstrual period is due (Kane, 2004). Spotting between periods is reasonably common among women and it is not health concern but it may be annoying at time (Darrach & Darragh, 2013). However, the participant highlighted that spotting is a disadvantage because it requires to buy wear panty liners. It is the financial cost of coping with such effects is what perhaps make it a disadvantage. Headaches One participant, Nono mentioned that when she got the injection, Depo-Provera, she began to experience headaches. The later explained that this was one of the disadvantages of using injectable contraceptives and it was one of the reasons why she stopped using Depo-Provera. According to (Schuster, 2007), headaches is common side effect of injectable contraceptives, Depo-Provera, it is suspected to be because of fluid retention. Increased appetite To on the list, one participant revealed that while she was using Depo-Provera she experienced increased appetite. Increased appetite is also another disadvantage of using injectable contraceptives. Kim, mentioned the following, “I would eat now, and I would be super hungry literally an hour later, but I would have eaten a lot of food”. There is a lot of misconception with regards to increased appetite and weight gain as direct side effects of using injectable contraceptives. Several scholars dismissed the idea that hormonal contraceptive causes weight gain. For instance, (Mahmood & Arulkumaran, 2013), argues that many women and health practitioners have a belief that there is an association between contraceptive (hormonal) and weight gain. (Mahmood & Arulkumaran, 2013), argued that there is little empirical evidence for significant weight alterations in relation to hormonal contraceptives. This idea has resulted in many women in quitting hormonal contraceptives (Barr, 2010). However, more studies should be conducted to clarify whether contraceptive use and weight gain is a myth or fact. Stigma The stigma associated around the use of injectable contraceptives was also highlighted as a disadvantage. One participant, Yaya, mentioned the following “when people knows that you are using contraceptives they start think you are sleeping around”. Analysing the phrase sleeping around, it is a language which mean you are either having sex with several different people, cheating and the phrase is usually used a pejorative manner (disapproval). for that reason, Nono, mentioned “a lot of people when go to the clinic to get the shot they use a low tone voice when speaking to the nurses to ensure that no one from the que may hear them talking about contraceptives”. Preferred methods One of the reasons which explains and necessitated the development of several different forms of contraceptives was to give women the liberty to choose their preferred method(s) which best suit their needs at a particular period (Brodie, 1997). Interesting the participants in this study they have more than one form of contraception and each person indicated her own preferred method. Yaya, she used injectable contraceptives (Depo-Provera) on three separate occasions. Although she appreciated the effectiveness of the method and the convenience it has in comparison to other methods she has used. In her own words she said, “I stopped using injectable contraceptives because of the side effects”, and when asked if she might use the method again her response was as follows, “no, pull-out was on fleek”. In this context the word fleek means on point, which therefore suggest that she meant pull-out method was working effectively for as her preferred method. One participant, Nono, was reluctant to mention her preferred method although she stressed that she will not use injectable contraceptives again because of the side effects she experienced. The other three participants, Chichi, Bongi, and Kim highlighted that injectable contraceptives as their preferred methods despite the shortcomings of the method. These three participants they have used more than three methods such as, pull-out, condoms and morning after pills. The main reason for preference for injectable contraceptives was based on the medical eligibility of the method and sexual liberty it provides. CHAPTER FIVE: SUMMARY AND CONCLUSION Introduction This final chapter provides a snippet of the major findings of the research study. The limitations of this study research study will be discussed to gain a realistic perspective of the implication of the research results. The chapter will conclude by highlighting areas that appear useful for future research projects to investigate. Review of the findings This research study was primarily exploratory and was located within the use of injectable contraceptives among wits female students. However, it attempted to contribute to the growing area of the use of contraceptive within universities. The study attempted to understand the broad use of injectable contraceptives among female wits students in relation to other contraceptives methods available to them. The use of injectable contraceptives, Depo-Provera, among wits female is a common practice. The research finding suggest that most females have either employed two or more forms contraceptives and injectable contraceptive, Depo-Provera their preferred form of contraceptive. Depo-Provera is the preferred for the following two reasons, medical eligibility and it allows them to fully express their sexual freedom. The self-confidence that most females have in injectable contraceptives perpetuate risk sexual behaviour. The research findings suggest that Wits female students are more concerned about avoid pregnancy and less concerned about protecting themselves from venereal diseases such as HIV/AIDS. This also suggest that the use of injectable contraceptives is to allow one have skin to skin sexual intercourse and then later prevent pregnancy. When choosing best contraceptives suited for one, there are number of factors that Wits female students consider. Some of these factors include, side effects and benefits of the method, cost of the methods, experiences of others (friends) who might have used, effectiveness of the method. Of these factors the two most important factors that they consider is the effectiveness of the method and side effects based on the experiences of others. There is variety of contraceptives that one may choose from. However, each method has its own pros and cons. As for injectable contraceptives, the findings from this study highlight the following as side effects of injectable contraceptives, Depo-Provera. Continuous bleeding, headaches, irregular periods, spotting, increased appetite and the cost of coping with the side effects. Despite of these side effects that female wits students experience when they use this method, injectable contraceptives remain to be there preferred method. Findings from this study suggest that most users of injectable contraceptives they are short sighted with regards to the side effects of injectable contraceptives. Most user they are aware of immediate side effects and not the long terms side effect and even when choosing factors they consider are only aligned to immediate side effects. Injectable contraceptives, Depo-Provera, has many long-term side effects such as, (Shoupe, 2004), there is greater when Depo-Provera is used for more than two year it may result in loss of bone mineral density, which makes osteoporosis more likely. According to (Wadia, 2012), Depo-Provera users have a slight increased risk of breast cancer. Implication of the Study While conducting the study it become apparent that when one contemplates on which birth control to use, students they sought to ask gather information from their friends who might have used contraceptives. The danger of this is that there is a lot of unverified information which shared between. Instead women, in this context wits female students who wish to use contraceptives they should first sought to seek information from professional health practitioners who administer contraceptives. It is important that when you consider using contraceptives one should consider both short term and long-term side effect of each method available to them. From this study most, female students who use contraceptives they are unaware of the long-term side effects of contraceptives. The danger is that when experience those effects it might have caused significant health complications. Risk sexual behaviour with tertiary institution for in this context, the University of the Witwatersrand is huge issue that needs urgent attention. Students tend to engage in risk sexual behaviour and they seem ignorant to the consequences of engaging in risk sexual behaviour. To curb such phenomena, they should be deliberate efforts to educate and discourage students in engaging risk sexual behaviour. Limitation of the study One of the limitation of this research study the nature of method employed. Qualitative approach was employed to in-depth knowledge of underlying reasons and motivations why female wits students use injectable contraceptives. However, in most cases qualitative in this case was employed mostly as open ended therefore, the participants had more control over the content of they shared. It meant the researcher was not able to verify the results objectively against what was stated by the participants. Secondly, time was another limitation which might have possibly have a significant impact on the comprehensiveness of this study. The researcher has limited time to carry out this research therefore it did not allow for comprehensive study. Time is essential is essential is research for instance time allows the researcher to conduct through analysis. In collecting data, the researcher conducted a focus group which was consisted of five participants. This another limitation is sense that it was a narrow group of people which means the group might not be a good representation of the entire wits females population who uses injectable contraceptives. Ideally the researcher should have conducted two separate focused group with different participants, this would enable the researcher to collect wide and broad data. This ultimately would also improve the credibility and reliability of the results of the study. For further study While conducting this research study, there are plenty of areas identified which need further exploration. The importance of exploring these fields is that it will contribute towards growing and improving richness of literature on contraceptives, address the issues around contraceptives especially the side effects. The two suggested fields which need further exploration include, the misconception on the issue of weight gain and contraception. Secondly, how to prevent or encourage tertiary student to abstain from risk sexual behaviour to be able to curb the spread of venereal diseases within tertiary institutions. References Allen, R. C. (2017). The Industrial Revolution: A Very Short Introduction. UK: Oxford University Press. Bailey, M. J. (2006). MORE POWER TO THE PILL: THE IMPACT OF CONTRACEPTIVE FREEDOM ON WOMEN’S LIFE CYCLE LABOR SUPPLY. 1-32. Barr, N. G. (2010). Managing Adverse Effects of Hormonal Contraceptives. American Family Physician , 1499-1506. 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Levels and Trends of Contraceptive Use as Assessed in 2002. USA: United Nations Publications. Ward, S., & Hisley, S. (2015). Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families (2nd ed.). Philadelphia: F A Davis. Welling, l. (2013). Psychobehavioral Effects of Hormonal Contraceptive Use. Evolutionary Psychology , 718-742. Appendix A.: Participant Information Sheet (Focus Group & Key informant). NB. All participants will read as individuals. The title of the study: An Enquiry into Attitudes of Female Students towards the Use of Injectable Contraceptives: The Case of Wits University. Good day. My name is Cleopas Munemo and I am currently in final year of studying Social Work at the University of Witwatersrand. As part of the requirements for the degree, I am conducting a study that explore female student’s perceptions and experiences towards the use of injectable contraceptives. It is hoped that the information gathered will assist in exploring the nature, use and effects of using injectable contraceptives. I want to explore whether students are equipped with know-how of injectable contraceptive and other contraceptive methods. In the end, the study will demonstrate the effects of injectable contraceptives among young female students. The outcome of this study will be informative, contributing to knowledge production on the use of contraceptives in general and enlighten women on the social and biological implications of using injectable contraceptives. I therefore, wish to invite you to participate in my study. If you accept my invitation, your participation would be entirely voluntary, and you are free to withdraw at any time without penalty. There are consequences or personal benefits of participating in this study. If you agree to take part in this study, you will be part of a Focus Group Discussion. The Focus Group Discussion will be approximately 2 hours long. If you choose to participate, you may withdraw from the study at any time and you may also refuse to answer any questions that you feel uncomfortable with answering. If you decide to participate, I will ask your permission to audio-record the interview. No-one other than the researcher and the supervisor will have access to the audio and transcript. The audio files and transcripts will be kept in a folder on a laptop for two years following any publications or six years if no publications emanate from the study. A copy of the interview transcript without any identifying information will be stored permanently and may be used for future research. Please be assured your name and personal details will be kept confidential and no identifying information will be included in the final report. The results of research may be used for academic purposes [including books, journals and conference proceedings] and a summary of findings will be made available to participants on request. Please contact me on [0743138378] [746286@students.wits.ac.za], or my supervisor Mr. Elvis Munatswa on [0785665840] [] if you have any questions regarding my study. We shall answer them to the best of our ability. If you have any concerns and complaints about the study, please contact Human Research Ethics Committee: Chairperson: Jasper.Knight@wits.ac.za or the Administrator: Mrs. Lucile Mooragan Tel [0117171408] Thank you for taking the time to participate in the study. Yours Sincerely Cleopas Munemo Appendix B. Consent Form for Participation in The Study (For FG & Key Informants). NB. All participants to read and sign individually The title of the study: An Enquiry into Attitudes of Female Students towards the Use of Injectable Contraceptives: The Case of Wits University. I here consent to participate in the research study. The purpose and procedures of the study have been explained to me. I understand that: · My participation in this study is voluntary and I may withdraw from the study without being disadvantaged in my way. · I may choose not to answer any specific questions asked if I do not wish to do so · There are no foreseeable benefits or risks associated with participation in this study. · My identity will be kept strictly confidential, and any information that may identify me will be removed from the interview transcript. · A copy of my interview transcript without any identifying information will be stored permanently in a locked cupboard and may be used for used research. · I understand that my responses will be used in the write up of an honours project and may also be presented in conferences, books chapters, journal articles or books. Name of Participant: …………………………………………………. Date: …………………………………………………. Signature: …………………………………………………. Appendix C: Consent Form for Audio-Taping Recording of the Interview The title of the study: An Enquiry into Attitudes of Female Students towards the Use of Injectable Contraceptives: The Case of Wits University. I hereby consent to tape-recording of the interview. I understand that: · The recording will be stored in a secure location (a locked cupboard or password protected computer) with restricted access to the researcher and the research supervisor. · The recording will be transcribed and any information that could identify me will be removed. · When the data analysis and write up of the research study is complete, the audio recording of the interview will be kept for two years following any publication or six years if no publications emanate from the study. · The transcript with all identifying information linked to me will be removed, will be stored permanently and may be stored for future research. · Direct quotes from the interview, without any information that could identify me, may be cited in the research report or other write-ups of the research. Name: …………………………………................... Date: ……………………………………………… Signature: ……………………………………………… Appendix D: Focus Group Discussion Guide Questions 1. How did you make the decision and what factors did you consider or influenced your decision to use injectable contraceptives? 2. How do you use and how often do you use injectable contraceptives? 3. Why do you use this particular contraception? 4. What other purposes do they serve for you? 5. What are the pros and cons of using injectable contraceptives? 6. What is your preferred contraceptive method(s)? 7. what are the side effects of using this method of contraception. 8. Is this contraceptive affordable and easily accessible? 9. Where do you get this contraception, what is its name, and who administers it to you? Appendix E: ethical clearance certificates image3.emf image1.png image2.jpg