Manuscript: Changes in weather season and utilization of RHS in selected South Sudan public health facilities

 

 

By: Dr. Emmanuel Timothy Thwol Onak1

 

Abstract

Background: Overall unmet needs for contraceptives among women are high; across the East Africa region including South Sudan, it ranges from 38.6 to 66.9%. Exploring the relationship between changes in weather season and utilization of RHS in selected South Sudan’s public health facilities, is key to developing and implementing locally appropriate public health responses.

Method: A qualitative study was conducted at South Sudan’s public health facilities in two (2) purposively selected States i.e., Western Equatoria and Central Equatoria. An interview guide was used to conduct in-depth interviews with the key informants who are knowledgeable about RHS. A data abstraction tool was also used to systematically collect data focused in obtaining the weather seasons and utilization data between the period of the years 2015 and 2020. 

Results: The research study investigates the relationship between changes in weather seasons and the utilization of RHS among women of reproductive age in Central Equatoria and Western Equatoria States, South Sudan, from 2015 to 2020, focusing on dry (Quarter 1) and rainy (Quarter 3) seasons. The findings reveal a consistent decline in RHS utilization during the rainy season, particularly during flooding events. Over 35% of women experienced extreme weather events, leading to constrained access to RHS clinics, primarily due to flooding. Extreme cold weather during the rainy season and floods disrupts transportation routes, hindering women from seeking RHS. The qualitative analysis underscores the need for strategies such as outreach programs, mobile clinics, improved infrastructure, early warning systems, and climate resilience in health facilities to address these weather-related barriers and enhance reproductive health outcomes for women in the region.

Conclusions: The study's findings underscore the significant impact of weather seasonality, particularly flooding, on the utilization of RHS in South Sudan, specifically in Central Equatoria and Western Equatoria. The study reveals that weather events such as heavy rainfall and flooding coincide with a consistent decline in the uptake of RHS, emphasizing the need for climate-informed RHS planning and delivery. Extreme weather events were reported to constrain access to RHS services for a substantial proportion of women, highlighting the importance of preparedness and resilience-building strategies. These findings align with existing research indicating climate change's adverse effects on maternal health and access to RHS. Overall, this research highlights the urgency of addressing climate-related barriers to ensure consistent and equitable access to RHS for women in South Sudan, especially in the face of increasing weather variability and extreme events.

Background

The study investigates the critical nexus between weather seasonality and the utilization of reproductive health services (RHS) in South Sudan, with a focus on addressing a multifaceted challenge impacting women's health and well-being in the African Region. As highlighted by WHO Africa (2021), women in this region face higher mortality rates due to communicable diseases, maternal and perinatal conditions, and nutritional deficiencies, underscoring the pressing need for comprehensive reproductive health services. Additionally, the disproportionate vulnerability of women and children to climate-related disasters, exemplified by mortality rates following extreme weather events, emphasizes the link between climate change and women's health (United Nations, 2015). These health disparities underscore the urgent need for improved access to RHS in the African Region.

Extensive research highlights the disproportionate impact of climate change-related weather seasonality on women's broader health, social, and economic well-being (Sorensen et al., 2018; Zeid et al., 2015). Women and children are reported to be up to 14 times more likely than men to die in the aftermath of disasters, including extreme weather events like hurricanes, wildfires, and flooding. While comparative mortality rates may vary across contexts, the literature consistently underscores the heightened vulnerability of women during climate-related disasters. These disasters disrupt health systems and hinder access to critical reproductive health services and supplies (Benjamin, 2016).

Climate change has been linked to negative maternal health outcomes, an increased prevalence of gender-based violence (GBV), and restricted access to RHS, which in turn negatively affect family planning, abortion, and STI outcomes (Women Deliver, 2021). Inadequate disaster-risk management (DRM) exacerbates these challenges, as climate-related disasters can lead to physical damage to health facilities and infrastructure, supply chain disruptions, and the loss of medical records. Consequently, the immediate and direct impact is reduced access to high-quality RH services such as post-exposure prophylaxis for HIV, HIV treatment, emergency contraception, and safe abortion services (Onyango & Heidari, 2017).

Beyond the immediate aftermath of climate events, there are enduring consequences for RH services. Disruptions in health services can compromise access to contraceptives, maternal and child care, HIV and STI testing and treatment, counselling, psychosocial support, abortion services, and post-abortion care for crisis-affected communities (Benjamin, 2016). Untreated STIs can lead to long-term health implications for women, including infertility, tubal or ectopic pregnancy, cervical cancer, and perinatal or congenital infections in infants born to affected mothers (Behrman & Weitzman, 2016). Reduced access to contraception can result in higher rates of unintended pregnancy, pregnancy complications, and maternal mortality (Behrman & Weitzman, 2016).

During natural or man-made crises, governance, support systems, and services often break down, significantly impacting girls' and women's sexual and reproductive health and rights (SRHR). Weaknesses in health systems during crises increase vulnerability to climate change, leading to gaps in access, availability, acceptability, and quality of RH information and services (Castro, 2020). The added fear, stigma, and harmful social norms in post-disaster settings exacerbate the utilization of RHS outcomes.

The African Region, particularly sub-Saharan Africa, experiences rapid population growth and high climatic vulnerability. Many communities depend on small-scale, rain-fed agriculture and livestock systems, which are susceptible to climate variations (Brown, 2015). Poor rainy seasons, characterized by late or sporadic rains, impact food availability and economic resources. These changes influence sexual behaviour, fertility goals, miscarriage rates, stillbirths, and overall maternal and child health (Grace, 2017). Additionally, direct impacts of climate and the natural environment, such as droughts, floods, heatwaves, and extreme weather events, can further affect RH outcomes and access to health services (Grace et al., 2015).

South Sudan, like other countries in the region, faces the destructive consequences of severe droughts, floods, and climate-driven challenges (UNFPA, 2021). These disasters often limit access to health services, including sexual and reproductive health, leaving women to give birth without adequate medical support. The lack of clean water and menstrual products further impairs women's and girls' dignity and access to essential menstrual hygiene management (UNHCR Africa, 2022). South Sudan experienced its worst flooding on record in 2021, highlighting the increasing frequency and severity of such events, which are likely to impact RHS utilization in public health facilities.

Although South Sudan has made progress in reducing maternal mortality rates, challenges persist, particularly in climate-affected areas. Ongoing violence, a decrease in the health budget, and high inflation rates have strained the population (Integrity, 2018). The Integrated Food Security Phase Classification reported that 48% of South Sudan's population faced acute food insecurity in January 2018 (IPC, 2018). The underfunding of humanitarian response plans, including RHS, exacerbates the crisis. This economic turmoil places additional pressure on donor-funded programs, including RHS.

While service delivery in South Sudan's health sector has been documented, there is a significant knowledge gap concerning the utilization of RHS in the public health sector, including health workforce and service delivery. Moreover, the linkages between climate change and the uptake of RHS have received limited attention, potentially due to inadequate governmental prioritization and the sensitive nature of the climate change-RHS relationship. This study aims to address this critical gap through a qualitative, exploratory investigation of the determinants of RHS uptake and utilization in public health facilities in South Sudan. The specific objective is to determine whether there is a relationship between changes in weather season and the utilization of RHS in selected public health facilities in South

Methods

The study utilized a mixed-methods approach to collect and analyse data. The first part was a longitudinal ecological study in which quarterly returns of weather seasonality/season and service utilization indicators were obtained from South Sudan National Bureau of Statistics, and the Ministry of Agriculture and Food Security, as well as the Health Management Information System database and health facilities. The scoping review and data collection were retrospective data derived from South Sudan’s respective Government Ministries from 2015 to 2020. The second part was an analytical cross-sectional study that was undertaken at the public health facilities and involved the health professionals.

An interview guide was used to conduct in-depth interviews with the key informants who are knowledgeable about RHS. The KIIs involved interviewing people who had particularly informed perspectives on an aspect of the RHS or who had a deep understanding of the health system at the state and county levels. The interview guide consisted of open-ended questions focusing on the specific objective of the study.  This data abstraction tool is a standard instrument used to systematically collect data from scientific reports in the development of the Guide to Community Preventive Services (the Guide). The data abstraction tool was focused on obtaining the weather seasons and utilization data between the proposed period of the year 2015 and 2020. The tool was designed to collect important information that helped generate useful data for analysis in that period as pertains to weather season and utilization of RHS.

The study borrowed mainly from two main theories i.e., the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These two theories have been adopted in studies to explain and predict utilization and uptake of RH service and proved to be useful in many empirical studies. Specifically, for developing a new behaviour or changing an existing behaviour of an individual, the HBM suggests the following unique and subjective beliefs of the person would be involved in the decision-making process: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action (Green et al., 2020). The four constructs of the HBM, perceived barriers, benefits, susceptibility and severity, were used to develop a predictive model for risky sexual practices in college students. Their results revealed that these constructs significantly explained 18% of variance in total number of risk behaviors, and 22% of variance in multiple sexual partnerships, but failed to predict condom usage in college women (Green et al., 2020). The HBM was shown to be a potentially useful theoretical framework for determining the uptake and utilization of RH services.

On the other hand, the TRA provides a framework to study attitudes toward behaviours with the ultimate goal being to predict and understand an individual’s behaviour. Rooted in value expectancy theories, the TRA assumes that humans are rational and make decisions for their actions by contemplating all the information available to them and the possible implications of the action (Glanz et al., 2015). Based on these assumptions, the TRA attempts to explain how intention converts into behaviour and what specific beliefs, attitudes, and subjective norms influence this transition. The TRA is composed of the following main constructs: behaviour, intention, and personal attitude. Behaviour is defined as being comprised of four elements: the action, the target at which the action is directed, the context in which it occurs, and the time at which it is performed. In addition, intention is the primary determinant of behaviour. It is believed that the stronger an individual’s intention toward a particular behaviour, the more successful he/she is expected to perform the behaviour.

Study sites

The study was conducted at South Sudan’s public health facilities in two (2) purposively selected States i.e., Western Equatoria and Central Equatoria. Approximately 83% of the population live in rural areas. The low population density (15/square kilometre) coupled with mobile pastoral communities and limited access due to the protracted crises poses a huge challenge to health service delivery. In these two selected States, data gathering was conducted in the four levels of the South Sudan health system, namely, the Boma Health Teams (community), Primary Healthcare Units (PHCU), Primary Healthcare Centres (PHCC) and the hospitals. These facilities are to a large extent aligned to the administrative subdivisions of the Country in both rural and urban areas (Ministry of Health, 2012; and WHO South Sudan, 2020). 

Sampling, recruitment of study participants and data collection

The qualitative part of this study included purposively selected 25 key informants (health workers). The selection of health workers providing RHS was made according to health cadres and geographical locations (state and administrative areas) of health facilities across the selected states. Data was also abstracted between the years 2015 to 2020 for the longitudinal ecological arm of this study. Retrospective data from the Health Ministry of Health and from the health facilities was obtained within the specified period to assess the utilization of the RH services between two weather seasons (wet and dry seasons). 

The interview guide consisted of open-ended questions focusing on the specific objectives of the study. It was a face-to-face conversation with the key informants that was recorded as part of note-taking. With the consent of the interviewee, the researcher recorded the conversation using a digital voice recorder. The researcher also observed the body language, expressions and other reactions to the questions during the interview. The data required to fill in the data abstraction form provided information on the intervention under study, evaluation setting and study population, outcomes, results, and study quality. The three sections of the form will consist of Part I. Classification Information, which was filled out by the chapter development team and reviewed and edited by the abstractors; Part II. Descriptive Information about the intervention, evaluation study characteristics, measurement of outcomes, and results; and Part III. Study Quality about the execution of the study.

Data analysis

In the proposed study, quantitative and qualitative approaches was used to analyse data emanating from different data collection tools. Data, once collected, was stored carefully to prevent damage or violations of subject privacy. The researcher ensured that unauthorized access to the files is not possible. Data files were stored in a computer that can only be accessed by the researcher and statistician and placed into files with password protection. Qualitative data and quantitative data were triangulated during post data analysis 

Data emanating from the questionnaires was entered into a computer file for analysis using Microsoft Excel Spreadsheet. Here the researcher used descriptive statistics such as mean, median, mode, percentage, frequency and range. Descriptive statistics are most helpful when the research is limited to the sample and does not need to be generalized to a larger population. The researcher conducted preliminary content analysis of the qualitative data to identify any common patterns and trends arising from the narratives regarding relationship between climate change and utilization of RHS. The narratives were written on the main themes and illustrated by state-specific data whenever possible. Sequel Data Analytics was also used to translate data for analysing and interpreting.

Ethical considerations

Researcher sought ethical approval from the Division of Research, Monitoring and Evaluation (Directorate of Planning and Coordination) in the Ministry of Health, and Research Ethics Committee (REC), Republic of South Sudan. Approval was also sought form Mount Kenya University Institutional Ethical Review Committee (IERC). The permission to access public health facilities and other offices was sought from the respective sectoral and departmental heads including the Ministry of Health and Local Governments in the Republic of South Sudan.

Participants who consent to participate in the research were accorded anonymity and confidentiality to protect them as well as boost confidence in order to obtain accurate information. They were also accorded exercise of free will in deciding whether to participate in the research activity. In addition, the participants reserved unconditional or absolute ‘right’ of withdrawal at any time and without giving any reason. This was expressly communicated before conducting the interviews and reduced in writing. All responses were recorded verbatim and reported objectively. The study was voluntary and the participants were able to withdraw from any point in the study if they so wish. 

The study strictly adhered to good practice ethics and principles for research and align with data collection and security/protection requirements. The researcher also took into consideration adaptations required to meet COVID-19 control regulations. They identified the level of risk for the team and communities and equipped both personnel and participants with the necessary protective equipment.

Results

Quantitative Analysis for Changes in Weather Season and Utilization of RHS

To explore the relationship between weather seasonality and utilization of RHS, the researcher analyzed the data from 2015 to 2020, focusing on Quarter 1 (dry season: January to April) and Quarter 3 (rainy season: August to November). These quarters were chosen as they represent a comparison between different weather conditions and are crucial for establishing a relationship between weather seasonality and utilization of RHS. Additionally, the selected RH services data (including family planning, HIV counselling & testing, and maternal & newborn care) of women of reproductive age attending RHS clinic was plotted against time period (Quarter 1 and Quarter 3).

Weather Patterns in Central Equatoria and Western Equatoria

Located at an elevation of 613.3 meters (2012.14 feet) above sea level, Central Equatoria has a Tropical wet and dry or savanna climate. The findings shows that the State’s yearly temperature is 29.52ºC (85.14ºF) and it is 0.02% higher than South Sudan’s averages. Central Equatoria typically receives about 130.25 millimeters (5.13 inches) of precipitation and has 197.45 rainy days (54.1% of the time) annually (see Figure 1).

Figure 1: Sunshine pattern in Central Equatoria and Western Equatoria

Source: Research Data (2023)

Located at an elevation of 636.91 meters (2089.6 feet) above sea level, Western Equatoria has a Tropical wet and dry or savanna climate. The findings establish that the State’s yearly temperature is 27.25ºC (81.05ºF) and it is -2.25% lower than South Sudan’s averages. Western Equatoria typically receives about 203.23 millimeters (8.0 inches) of precipitation and has 223.82 rainy days (61.32% of the time) annually (see Figure 2).

Figure 2: Rain pattern in Central Equatoria and Western Equatoria

Source: Research Data (2023)

Trend and Seasonal Components (2015 to 2020) of RHS Visits 

Figures 3, 4 and 5 show that there were seasonal variations in the number of family planning visits, HIV counselling & testing visits; and maternal and newborn care visits since there were a number of peaks and troughs each year. The trend curve shows that there was a steady increase in the RHS all through from the first and third quarters of 2015 up to the first and third quarters of 2020. However, there are some seasonal differences in the selected RHS attendance in terms of first and third quarters all from 2015 to 2020, there is a consistent decline in attendance during the third quarters.

Figure 3: Scatter and trend plots of family planning visits in selected public health facilities

Source: Research Data (2023)

Figure 4: Scatter and trend plots of HIV counselling and testing visits in selected public health facilities

Source: Research Data (2023)

Figure 5: Scatter and trend plots of maternal and newborn care visits in selected public health facilities

Source: Research Data (2023)

 

The selected RH services data of respondents attending the RHS clinic was plotted against the time period of 2015 to 2020 focusing on Quarter 1 and Quarter 3 (see Figures 3, 4 and 5). These two quarters represent a comparison between the dry (January to April) and rainy (August to November) seasons in Central Equatoria and Western Equatoria essential for establishing a relationship between weather season and utilization of RHS (see Figures 1 and 2).

The findings show that there are some seasonal differences of uptake and utilization of RHS in the first and third quarters all through 2015 to 2022 with a consistent decline in uptake of RHS during the third quarters. This coincides with the rainiest season of August and September (see figure 4.9 and 4.10) where there are high chances of experiencing flooding. The findings imply that there are long-lasting impacts on the uptake and utilization of RHS after a climate event such as flooding takes place. It was further established that disruptions in people’s household and public health facilities was likely to compromise uptake and utilization of RHS across the selected public health facilities.

Qualitative Analysis for Changes in Weather Season and Utilization of RHS

The thematic analysis highlights the significant influence of extreme weather events on the utilization and uptake of reproductive health services in Western Equatoria and Central Equatoria States in South Sudan.

The theme identified is the impact of extreme weather events, including drought and flooding, on the utilization and uptake of RHS. The weather conditions in Western Equatoria and Central Equatoria States, characterized by very cold temperatures during the rainy season and hot temperatures during the dry seasons, pose challenges for women seeking RHS. The extreme cold weather during the rainy season hinders women's willingness to go out and visit reproductive health clinics, potentially leading to reduced utilization. Similarly, floods resulting from heavy rains can disrupt transportation routes, making it difficult for women to access public health facilities and avail of RHS.

“The extreme cold weather during the rainy season acts as a deterrent for women seeking reproductive health services. It creates discomfort and poses health risks, making it less likely for women to venture out to access public health facilities. Addressing this challenge requires strategies such as improving the availability and accessibility of services closer to communities, including outreach programs and mobile clinics, to mitigate the impact of extreme cold weather on service utilization.” (FGD-Media, 2023)

Another theme revolves around limited access to RHS due to extreme weather conditions. The cold weather during the rainy season may discourage women from venturing outside their homes, especially for non-emergency services like reproductive health. Additionally, floods can render roads impassable, making it challenging for women to travel to public health facilities. These access barriers limit the utilization of RHS and negatively impact the overall reproductive health outcomes for women of reproductive age.

“Floods resulting from heavy rains further exacerbate the barriers to RHS. The disruption of transportation routes and infrastructure makes it challenging for women to access public health facilities, particularly during emergencies or when seeking routine reproductive health services. To address this issue, it is crucial to strengthen the resilience of health systems by improving transportation infrastructure, implementing early warning systems, and establishing contingency plans to ensure continuous service provision during extreme weather events.” (KI-Nurse, 2023)

Solutions to overcome these weather-related barriers should involve a multi-sectoral approach. Collaborating with meteorological departments and disaster management authorities can facilitate the integration of weather forecasts and early warning systems into the planning and delivery of reproductive health services. Engaging local communities through awareness campaigns and community-based approaches can also help in building resilience and preparedness, enabling women to make informed decisions and seek reproductive health services even during challenging weather conditions.

It is important to prioritize climate resilience in the design and management of reproductive health programs and services. This includes assessing the vulnerability of health facilities to extreme weather events, incorporating climate change adaptation strategies into facility infrastructure planning, and strengthening the capacity of health workers to respond effectively to climate-related challenges. By addressing the climate-related barriers and ensuring that reproductive health services are resilient to extreme weather events, South Sudan can enhance the utilization and uptake of reproductive health services, ultimately improving the reproductive health outcomes for women of reproductive age in Western Equatoria and Central Equatoria States.

Discussion

The study's findings, which examined the relationship between changes in weather seasons and the utilization of RHS in South Sudan, were analyzed through the lens of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These two theoretical frameworks provided valuable insights into the mechanisms and factors influencing individuals' decisions regarding RHS utilization. For instance, the HBM highlights the importance of an individual's perception of their susceptibility to a health condition and the severity of its consequences. In the case of South Sudan, where extreme weather events like flooding are prevalent, individuals may perceive themselves as susceptible to reproductive health risks due to the disruption of health services caused by flooding. The severity of these consequences may encompass complications related to pregnancy, STIs, and maternal and child health issues. These perceptions could motivate individuals to seek reproductive health services as a preventive measure. 

In addition, the TRA posits that attitudes toward a behaviour influence an individual's intention to engage in that behaviour. Attitudes can be shaped by the perceived benefits and risks associated with the behaviour. In the case of RHS utilization, attitudes may be influenced by the perceived benefits of accessing these services for reproductive health, such as family planning and STI prevention. However, during adverse weather conditions, individuals' attitudes toward RHS utilization may become less favourable due to perceived barriers and challenges associated with accessing services.

The findings of the study indicate that a significant proportion of the respondents (72.5%) had utilized reproductive health services in the selected public health facilities, while 27.5% reported not having utilized any services in the past 12 months.  Studies conducted in the region reveal that approximately 17% of all women in Sub-Saharan Africa and 23% of married or in-union women have an unmet need for RH services (United Nations, 2019). However, despite the significant utilization of RH services, the current study found that the majority of women (86.3%) reported not receiving all the RHS they were seeking in the selected public health facilities. This highlights a gap in the availability of comprehensive reproductive health services, indicating a need for improvement in the facilities' service delivery.

Among the RHS, family planning and prevention and management of sexually transmitted infections (STIs) were the most utilized, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counselling and testing were also commonly used services, representing 18.1% and 15.3% of the respondents, respectively. However, studies conducted across Africa show that the majority of women of reproductive age would like to stop or delay childbearing but only 28% of women are using modern methods of family planning (WHO Africa, 2020). In addition, this study revealed that prior to their latest visit, a significant portion of the respondents (77.3%) were not aware that public health facilities provided free access to RHS. This lack of awareness may have hindered women's utilization of these services, emphasizing the importance of enhancing public awareness campaigns to ensure women are informed about the availability and accessibility of RHS.

From the longitudinal ecological study, it was observed seasonal variations in the number of visits for family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020. The trend analysis indicated a consistent increase in the uptake of RH services throughout the years. A previous study conducted in South Sudan found that the return of peace in South Sudan presented opportunities unlike before, including utilization and uptake of RHS among women of reproductive health (Kane, et al., 2016). However, this current study showed that there were specific declines in family planning, HIV counselling and testing, and maternal and newborn care attendance during the third quarter of each year from 2015 to 2020. This finding suggests a potential need for targeted interventions to address barriers or factors affecting attendance during the third quarter period.

The findings of this research objective shed light on the utilization and availability of RHS among women of reproductive age in South Sudan's public health facilities. The findings highlight the need for improved service provision to ensure comprehensive RHS are accessible to all women. Increasing awareness among the target population about free access to RHS can also contribute to improved utilization. Thus, addressing the seasonal differences in attendance, particularly for family planning services, HIV counselling and testing, and maternal and newborn care may require targeted strategies to ensure consistent access throughout the year.

Limitations

There are certain limitations associated with this study. Although the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) offer valuable insights into individual behaviour, it's important to acknowledge that they are somewhat simplified models. Real-world decision-making is often shaped by intricate interactions among numerous factors, encompassing social, cultural, and economic determinants. While the HBM and TRA provide theoretical frameworks to grasp behaviour, they may not encompass the entirety of variations in reproductive health service (RHS) utilization. Factors beyond the scope of these theories might exert considerable influence on RHS utilization patterns

This study drew upon existing data sources, including government records and health facility databases. However, it's essential to acknowledge that the accuracy and completeness of these data sources may vary, potentially introducing measurement errors or biases during the analysis. Moreover, the study utilized retrospective data spanning from 2015 to 2020, which may be susceptible to recall bias as participants may have limitations in accurately remembering events or experiences over an extended period. Furthermore, the selection of health professionals for interviews followed a purposive approach, which could potentially introduce selection bias. This means that the health workers chosen for interviews may not be fully representative of all health professionals, and this could limit the generalizability of the qualitative findings. 

While the study has identified associations between weather seasonality and RHS utilization, it's important to note that it may not definitively establish causality. There could be other unmeasured factors that influence the observed patterns. Additionally, the study primarily relies on quantitative data sourced from government records and health facilities. To gain a more comprehensive understanding of the factors influencing RHS utilization, it could be beneficial to incorporate additional qualitative data sources, such as conducting direct interviews with service users. This would provide richer insights into the subject matter.

To mitigate the limitations of this study effectively, several strategies can be envisaged. In future research, it would be beneficial to delve into and embrace more holistic theoretical frameworks that accommodate the intricate nature of behaviour, encompassing factors such as social, cultural, and economic determinants. The integration of multiple theories or models might offer a more nuanced and comprehensive understanding of RHS utilization. Moreover, to establish a stronger causal link between weather seasonality and RHS utilization, forthcoming studies could adopt more robust research designs, such as experimental or quasi-experimental approaches. Additionally, exploring mediating and moderating factors could aid in clarifying the causal pathways involved in this relationship, enhancing the depth of analysis and insight.

Conclusions

The HBM underscores the significance of an individual's perception of susceptibility to health conditions and the severity of potential consequences. In South Sudan, where extreme weather events like flooding are prevalent, individuals may perceive themselves as vulnerable to reproductive health risks due to disruptions in health services caused by flooding. Furthermore, the TRA highlights that attitude towards behavior play a pivotal role in shaping an individual's intention to engage in that behavior. Attitudes can be molded by the perceived benefits and risks associated with RHS utilization. 

The longitudinal ecological study uncovered seasonal variations in the utilization of family planning, HIV counseling and testing, and maternal and newborn care services from 2015 to 2020. While there was a general increase in RHS uptake over the years, the study noted specific declines during the third quarter of each year. This finding suggests the need for targeted interventions to address barriers or factors affecting RHS attendance during the third quarter period. In addressing the limitations of this study, future research should consider more comprehensive theoretical frameworks that account for the multifaceted nature of behavior and incorporate a broader range of factors. Robust research designs, including experimental or quasi-experimental approaches, could strengthen causal inferences, and investigating mediating and moderating factors may provide deeper insights into the observed relationships.

In summary, this study underscores the importance of understanding the impact of weather seasonality on RHS utilization and highlights the need for improved service provision, increased awareness, and targeted interventions to ensure consistent access to reproductive health services throughout the year in South Sudan.

Acknowledgements:

This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.

Funding Acknowledgements:

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Competing Interests:

Author(s) declares there were no competing interests

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