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DR. EMMANUEL TIMOTHY THWOL

By DR. Emmanuel Timothy Thwol Onak (PhD)

 

Abstract

Background: Africa constitutes roughly 10% of the global population and witnesses around 20% of worldwide childbirths. Alarmingly, nearly half of all maternal deaths during pregnancy and childbirth occur in this region. The World Health Organization (WHO) estimates that inadequate reproductive health contributes to approximately 18% of the overall global disease burden, with women of reproductive age bearing 32% of this burden. In light of these concerns, this study investigates the sociocultural elements influencing the adoption and use of Reproductive Health Services (RHS) in specific public health facilities in South Sudan while also assessing the extent to which these services are being embraced and utilized.

Method: The research utilized a mixed-methods strategy, comprising a longitudinal ecological study and an analytical cross-sectional investigation, which took place in specifically chosen states - Western Equatoria and Central Equatoria. The study focused on women aged 15 to 49 who were seeking healthcare services during the study timeframe. Data collection methods encompassed structured questionnaires and data abstraction instruments. The quantitative data analysis encompassed descriptive statistics and inferential analyses.

Results: 

The study's findings reveal that a significant portion of respondents (72.5%) had utilized reproductive health services in selected public health facilities, with family planning and prevention/management of STIs being the most commonly used services, each accounting for 25.1% of the sampled population. Maternal and newborn care and HIV counseling/testing were also frequently accessed, at 18.1% and 15.3%, respectively. Over the years, there was a consistent increase in the uptake of reproductive health services, although specific declines were observed during the third quarter of each year from 2015 to 2020 for family planning, HIV counselling/testing, and maternal/newborn care. The study noted that a significant relationship existed between the age of the respondents and service utilization, with 53.5% of respondents aged 30 and older. Additionally, there was a statistically significant link between the respondent's place of residence and service utilization, with individuals in urban areas being twice as likely to utilize services compared to those in rural areas. The study also found a significant relationship between the educational level of the respondents and the uptake of reproductive health services.

Conclusions: 

While the study reveals a positive trend in the overall uptake of RHS, specific declines in family planning, HIV counselling/testing, and maternal/newborn care during certain quarters require attention. Notably, age, place of residence, and educational levels significantly influence service utilization, with older individuals, urban residents, and those with higher educational attainment more likely to access reproductive health services. To address these disparities and improve reproductive health outcomes, policy and healthcare interventions should be tailored to the unique sociocultural contexts and demographic characteristics of South Sudan. Greater emphasis on education and awareness campaigns, particularly in rural areas, is recommended to promote comprehensive RHS utilization and reduce maternal mortality rates. Additionally, sustained efforts to enhance the quality and accessibility of these services, especially in the specified areas of decline, are crucial to advancing reproductive health in the region.

Introduction

Reproductive Health (RH) is a fundamental component of overall well-being, encompassing physical, mental, and social aspects that go beyond the mere absence of disease or infirmity, as defined by the World Health Organization (WHO, 2021). RH extends to all matters related to the reproductive system, its functions, and processes. The United Nations Population Fund (UNPF, 2019) further emphasizes that RH includes the ability to reproduce, regulate fertility, engage in safe and fulfilling sexual relationships, and achieve successful outcomes in reproduction, such as infant and child survival, growth, and healthy development. It also entails safe pregnancy and childbirth, risk-free fertility regulation, and the assurance of safe sexual experiences.

The WHO RH Strategy, established in 2004 and guided by international human rights principles, outlines the core elements of Sexual and Reproductive Health (SRH), aiming to enhance the well-being of communities (WHO Africa, 2020). These core aspects encompass improving antenatal, perinatal, postpartum, and newborn care; providing high-quality family planning services, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer, and other gynaecological morbidities; and promoting sexual health. Additionally, the strategy underscores the critical importance of preventing and responding to violence against women to improve reproductive health outcomes.

Despite some progress within the European Region, challenges persist. While the contraceptive prevalence rate has increased from 55.6% in 2000 to 61.2% in 2015, there remains a significant lack of information and awareness concerning critical RH issues such as sexuality, family planning, pregnancy, childbirth, sexually transmitted infections, infertility, cervical cancer prevention, and menopause (WHO Europe, 2021). The region faces complications in pregnancy and childbirth, unsafe abortions, reproductive tract infections, and sexual violence, which contribute to avoidable cancer-related deaths among women. Notably, there are disparities in RH within and between countries. A study in 13 European Union countries in 2012 highlighted the higher proportion of women with unmet family planning needs among people living with HIV (PLHIV) compared to the general population (UNPF, 2012). New HIV infections in the European Region increased by 75% since 2005, and the region reported nearly 137,000 new HIV diagnoses in 2019 (WHO Europe, 2020).

Contraception and abortion are significant concerns in Asia. In 2017, approximately 132 million women of reproductive age in Asia had an unmet need for modern contraception, leading to an estimated 53.8 million unintended pregnancies, two-thirds of which ended in abortion (Center for Reproductive Rights, 2021). The majority of these abortions occurred in South and Central Asia, including India, and Eastern Asia, including China. Although the proportion of unsafe abortions is uncertain, it is estimated that 4.6 million women in Asia (excluding Eastern Asia) experience complications from unsafe abortions annually (Guttmacher Institute, 2017). Adolescent childbearing rates have decreased in most Asian and Pacific countries, but they remain high in South and South-West Asia, particularly in Bangladesh (35%), Nepal (21%), and India. South Asia also grapples with a high prevalence of child marriage, with 45% of women aged 20-24 reporting marriage before the age of 18 and 17% before the age of 15 (Center for Reproductive Rights, 2021). Maternal mortality related to pregnancy and childbirth affected approximately 85,000 women in the region in 2015, with 92% of these maternal deaths occurring in just 12 countries (UNICEF, 2021).

In Africa, women face a higher risk of death from communicable diseases, maternal and perinatal conditions, and nutritional deficiencies. About 30% of women worldwide, including 468 million aged 15-49, experience anaemia, with the majority living in Africa (48-57%) due to iron deficiency. Gender inequity, poverty, weak economic capacity, and sexual and gender-based violence, including Female Genital Mutilation (FGM), present significant obstacles to improving women's health in the African Region (United Nations, 2015). Despite Africa accounting for one-tenth of the world's population and 20% of global births, nearly half of maternal deaths occur in this region. Poor reproductive health accounts for up to 18% of the global burden of disease and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to essential RH interventions, particularly family planning, remains limited, with low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).

However, just as health outcomes have improved globally in the past two decades, South Sudan has also seen substantial progress, such as a decline in maternal mortality, neonatal mortality, infant mortality, and under-five stunting (World Bank, 2018). Access to Reproductive Health Services (RHS), including antenatal care and contraception, has significantly increased in Sub-Saharan Africa (United Nations, 2015). Nevertheless, access to healthcare, especially RH services, remains a significant challenge in South Sudan due to persistent conflicts and a fragile peace process (Pendle, 2014). In the East African region, including countries like Uganda, Tanzania, and Kenya, maternal mortality remains high compared to developed nations, highlighting the need for improved RH services (UNICEF, 2016). The use of modern contraceptives is low, and unmet family planning needs affect a significant proportion of married women (United Nations, 2015).

In the context of South Sudan, capacity constraints and a challenging governance environment affect the implementation of basic health services and government policies. Reports suggest a lack of progress in building government capacity (Larson et al., 2013), and economic and social challenges, including budget cuts for health, inflation, and food insecurity, exacerbate the situation (Integrity, 2018; IPC, 2018). The economic crisis affects programs funded by donors, including RH services (Integrity, 2018). Consequently, the utilization and uptake of RH services in South Sudan are subject to these complexities, making this an issue of critical importance.

This study's rationale is rooted in the urgent necessity to comprehend and enhance the utilization of Reproductive Health Services (RHS) in South Sudan, a region characterized by persistent conflict, fragile governance, and substantial economic challenges. South Sudan has grappled with prolonged instability, violence, and a feeble healthcare infrastructure, resulting in limited access to essential healthcare services, particularly reproductive health. Consequently, investigating the determinants of RH service uptake in this complex environment is not only justifiable but also profoundly pertinent. The relevance of this study extends to multiple dimensions. Firstly, it is essential to devise effective strategies to improve reproductive health outcomes in conflict-affected regions like South Sudan, where ongoing instability has triggered economic crises and healthcare infrastructure limitations, making it imperative to ensure access to vital RH services, thereby reducing maternal and infant mortality, bolstering family planning, and addressing the consequences of unmet reproductive health needs. Secondly, the study's global relevance is underscored by the fact that South Sudan's challenges are not unique; many conflict-affected regions worldwide face analogous difficulties in delivering healthcare services, including reproductive health. Therefore, the study's findings offer valuable insights for other nations and organizations working in such settings, providing guidance on strategies to surmount challenges and enhance RH service utilization. 

The primary question guiding this study is: "What are the determinants of Reproductive Health (RH) services uptake and utilization in South Sudan, and how do sociocultural factors impact these processes?" To address this overarching question, the study has two specific objectives: 1) to assess the level of uptake and utilization of RH services in selected South Sudan public health facilities, and 2) to examine the sociocultural factors influencing the uptake and utilization of RH services in these facilities. These objectives guide the study's focus on understanding the factors influencing the utilization of RH services in a conflict-affected and resource-constrained setting.

Methods

The study employed a mixed-methods approach to gather and analyze data. It consisted of two main parts: a longitudinal ecological study using retrospective data from South Sudan's Ministry of Health covering the period from 2015 to 2020 and an analytical cross-sectional study conducted at public health facilities involving women of reproductive age.

In the analytical cross-sectional study, quantitative data was collected from women of reproductive age visiting selected public health facilities during the study period. A structured questionnaire with only closed-ended questions was developed as the primary research instrument, focusing on specific study objectives. This questionnaire aimed to assess the level of reproductive health service utilization and socio-cultural factors. Additionally, a data abstraction tool, a standard instrument, was employed to systematically collect data from the Health Management Information System database and health facilities. This tool was used to extract utilization data from the period between 2015 and 2020.

The study drew its theoretical framework primarily from two established theories: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These theories have been widely used in previous studies to explain and predict the utilization and uptake of reproductive health services. The Health Belief Model (HBM) focuses on unique and subjective beliefs that influence an individual's decision-making process. It includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. These constructs were used to develop a predictive model for risky sexual practices in college students and were found to significantly explain variations in risk behaviours and sexual partnerships. The Theory of Reasoned Action (TRA) provides a framework for studying attitudes toward behaviours and aims to predict and understand an individual's behaviour. It assumes that individuals are rational and base their actions on a thoughtful consideration of available information and potential consequences. The TRA comprises key constructs, including behaviour, intention, and personal attitude. The intention is considered the primary determinant of behaviour, with stronger intention indicating a higher likelihood of performing a particular behaviour.

This methodological approach allowed for a comprehensive examination of reproductive health service utilization and the underlying factors, drawing on well-established theoretical frameworks.

Study sites

The study was conducted at public health facilities in two specific states of South Sudan, namely, Western Equatoria and Central Equatoria. South Sudan's population predominantly resides in rural areas, accounting for approximately 83% of the total population. The rural landscape is characterized by low population density at 15 individuals per square kilometre, which, combined with the presence of mobile pastoral communities and restricted access due to prolonged conflicts, presents substantial challenges to healthcare service provision. Data collection was carried out at all four levels of the South Sudan health system, encompassing the Boma Health Teams representing the community level, Primary Healthcare Units (PHCU), Primary Healthcare Centers (PHCC), and hospitals. These healthcare facilities are strategically aligned with the country's administrative subdivisions, serving both rural and urban regions (Ministry of Health, 2012; WHO South Sudan, 2020).

Sampling, recruitment of study participants and data collection

The primary respondents for this study were situated in public health facilities located in Western Equatoria and Central Equatoria. The quantitative sampling approach employed a multi-stage cluster random sampling method, involving two distinct stages: the selection of health facilities and the subsequent selection of participants.

In the first stage of sampling, the selection of health facilities commenced within each of the chosen states. A comprehensive list of existing public health facilities was compiled, and from this list, a systematic random sampling method was employed to designate a specific facility as a sample for the study. A minimum of three public health facilities were randomly chosen in each state.

The second stage of sampling centred on the selection of participants; a process facilitated by probability proportionate to size. Utilizing available population lists, such as the 2018 census, which included women of reproductive age falling within the bracket of 15 to 49 years, from the pre-selected states of Western Equatoria and Central Equatoria. The sampling interval was computed by dividing the total population of the program area by the number of women of reproductive age who visited health facilities. A systematic random start number was used to identify the first client. Subsequent clients were determined by incrementing the random number by the sampling interval, and this process continued until the required number of clients was attained.

The researcher assumed the responsibility for both the collection and management of field data. Preceding the commencement of data collection, the researcher recruited and conducted comprehensive training for five research assistants (RAs). The RAs were thoroughly acquainted with the study's objectives and methodological approach, and they received training in the administration of data collection tools, which encompassed a detailed review of the tools and practical exercises. Ethical considerations, data confidentiality protocols, and field logistics were also integral parts of the training. Prior to the commencement of the interview, written consent was obtained from the participants, and the participants were assured of the confidentiality of their information. The interviews were initiated with a concise introduction, elucidating the interviewer's identity, the organization they represented, and the study's objectives. The data collection tools were administered through face-to-face interviews.

Additionally, the data needed for completing the data abstraction form encompassed information related to the intervention under investigation, evaluation setting, study population, outcomes, results, and study quality. The form comprised three key sections: Part I, which pertained to Classification Information and was initially filled out by the chapter development team and subsequently reviewed and edited by the abstractors; Part II, which covered Descriptive Information concerning the intervention, evaluation study characteristics, measurement of outcomes, and results; and Part III, which delved into Study Quality, evaluating the execution of the study.

Data analysis

The data derived from the questionnaires and the data abstraction form underwent a comprehensive data analysis process. Initially, all data were entered into a computer file using Microsoft Excel Spreadsheet. Subsequently, the data were exported to IBM Statistical Package for the Social Sciences (SPSS) version 23, where all sub-files were amalgamated into one master file for further analysis. The initial phase of data analysis was data preparation, which involved transforming raw data into a comprehensible and meaningful format. This process included data validation, editing, and coding.

Various statistical techniques were then employed to identify significant correlations between variables and assess the impact of one variable on another. Descriptive statistics, such as mean, median, mode, percentage, frequency, and range, were utilized to gain an overview of the data. Descriptive statistics are particularly valuable when the scope of the research is confined to the sample and does not necessitate generalization to a larger population. For example, when comparing the percentage of youth utilizing RHS in different states, descriptive statistics provide sufficient insights. Subsequently, cross-tabulations were utilized to delve deeper into the dataset. Cross-tabulations are a means to elucidate the relationship between two variables and are commonly employed to compare outcomes across demographic groups. They allow for the examination of results based on factors like age and the utilization of RHS.

To assess hypotheses, the researcher calculated measures of statistical significance, which ascertain whether findings are statistically meaningful or merely the result of chance. Statistical significance was indicated by the p-value statistic. Typically, a p-value of less than 0.05 is considered statistically significant, signifying a less than 5% probability that the results occurred by chance. Furthermore, the researcher applied various inferential analyses, including correlation, regression, and analysis of variance where relevant. Linear regression was employed, for instance, to predict the value of one variable based on another. This approach allowed the exploration of whether the utilization of RHS could be predicted based on factors like climate change or socio-cultural characteristics. Additionally, one-way analysis of variance (ANOVA) was used to determine if statistically significant differences existed between the means of two or more independent groups.

Ethical considerations

Ethical considerations were paramount throughout the course of this study. Prior to the commencement of data collection, the researcher diligently sought ethical approval from the Division of Research, Monitoring and Evaluation within the Directorate of Planning and Coordination at the Ministry of Health, as well as the Research Ethics Committee (REC) of the Republic of South Sudan. Additional approvals were obtained from the Institutional Ethical Review Committee (IERC) of Mount Kenya University. In accordance with ethical standards, formal permissions were also secured from the respective sectoral and departmental heads, including the Ministry of Health and Local Governments within the Republic of South Sudan, to access public health facilities and other relevant offices.

The participants who willingly consented to take part in the study were assured of strict anonymity and confidentiality. These measures were implemented to safeguard their identities and instil confidence in the research process, thereby promoting the provision of accurate information. Furthermore, participants were granted the unequivocal right to exercise their free will, allowing them to decide whether they wished to participate in the research. The option of withdrawal from the study was extended to participants at any point, without the requirement to provide a reason. This opportunity was explicitly communicated to participants before the commencement of interviews and was also documented in writing.

In adhering to high ethical standards and principles for research, the study conformed to data collection, security, and protection requirements. Special consideration was also given to adaptations necessary to comply with COVID-19 control regulations. The risk level to both the research team and the communities was identified, and all personnel and participants were provided with essential protective equipment to mitigate risks effectively.

Results

Socio-Demographic Characteristics

Table 1 provides a comprehensive overview of the demographic characteristics of the study's respondents. The data reveals that a significant portion of the participants (53.5%) were aged 30 years and older, while the remaining 46.5% were younger, with the age range spanning from 17 to 49 years. The mean age was calculated at 29.8 years, with a standard deviation of 7.80. Regarding marital status, the majority of respondents indicated that they were married (67.0%), followed by those who reported being single (20.5%). A smaller percentage of respondents identified as divorcees (6.3%), and another 6.3% stated they were widowed.

Table  1: Socio-demographic characteristics of women of reproductive health visiting selected public health facilities in South Sudan

Variable 

Category

Frequency

Percentage (%)

State 

Central Equatoria

232

58.0

Western Equatoria

168

42.0

       

Age

Younger than 30 years

186

46.5

30 years and older

214

53.5

       

Marital status 

Single 

82

20.5

Married 

268

67.0

Divorced 

25

6.3

Widowed 

25

6.3

Place of residence

Urban

74

18.5

Rural

326

81.5

Employment status

In school or training

48

12.0

Paid/wage/paid in kind employed

19

4.8

Self-employed

121

30.3

Unemployed

173

43.3

Unemployed but not seeking work for other reasons

39

9.8

       

Household wealth status 

Poor (<500,000 SSP)

365

91.3

Middle (500,000 SSP -1,000,000 SSP)

35

8.8

       

Religion 

Christian

348

87.0

Traditional

52

13.0

       

Education status

No school

147

36.8

Only traditional/non-formal school

53

13.3

Dropped-out of school

27

6.8

Completed secondary

173

43.3

Source: Research Data (2023)

Geographically, over 80% of the participants resided in rural areas, while the remaining 18.5% lived in urban regions. The employment status of the respondents varied, with the highest proportion reporting being unemployed (30.3%), closely followed by those who identified as self-employed (30.3%). In terms of household wealth status, the analysis categorized a substantial majority of respondents (91.3%) as belonging to the "poor" category, as their household income fell below 500,000 South Sudanese Pounds (SSP).

Religiously, 87% of the respondents identified as Christians, while a smaller percentage (13.0%) stated they followed traditional belief systems. When examining the education level of the participants, it was found that 43.3% had completed their education up to the secondary school level, followed by 36.8% who had not attended any formal schooling. This rich demographic information lays the foundation for a more in-depth understanding of the study's participants (refer to Table 1).

Level of Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities

Reproductive health services received in the past 12 months

Inquiries were made to determine whether women of reproductive age, during their visits to the clinics, had utilized the Reproductive Health Services (RHS) offered within the selected public health facilities over the preceding 12 months. Figure 1 presents the findings, indicating that a substantial majority of the respondents (72.5%, 290 individuals) had indeed taken advantage of the available RHS during this period. In contrast, a noteworthy segment of the participants (27.5%, 110 individuals) reported that they had not utilized RHS within the past 12 months. This information sheds light on the utilization of RHS among the study's respondents.

Figure 1: Users and non-users of RH services in the past 12 months

Source: Research Data (2023)

The study's respondents, women of reproductive age visiting the designated public health facility, were surveyed to ascertain the types of services they had received at the facility over the previous 12 months. Figure 2 illustrates the outcomes, highlighting that family planning services (25.1%) and prevention and management of Sexually Transmitted Infections (STIs) (25.1%) were the most frequently utilized Reproductive Health (RH) services among the surveyed women visiting these facilities. Additionally, maternal and newborn care services, as well as HIV counselling and testing, emerged as other commonly accessed services, accounting for 18.1% (290 respondents) and 15.3% (244 respondents) of the sampled population, respectively. These findings underscore the prevalence of specific RH services among the women utilizing these health facilities.

Figure 2: List of services received in the selected public health facilities

Source: Research Data (2023)

Temporal patterns in reproductive health service clinic utilization in public health facilities from 2015 to 2020

The study investigated attendance trends at reproductive health services (RHS) clinics in public health facilities between 2015 and 2020, specifically focusing on services such as family planning, HIV counselling and testing, and maternal and newborn care. The data from women of reproductive age attending the RHS clinics during the first and third quarters of each year were analyzed and plotted, revealing notable patterns.

Figure 3 demonstrates seasonal variations in clinic attendance for family planning, HIV counselling and testing, and maternal and newborn care services, with recurring peaks and troughs each year. The trend curve for all three services indicates a consistent increase in utilization from the first to the third quarters spanning from 2015 to 2020. Notably, the third quarter consistently shows a decline in attendance, highlighting these seasonal fluctuations in service utilization.

 

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

Source: Research Data (2023)

These findings underscore the dynamic nature of attendance at RHS clinics over the study period, characterized by seasonal fluctuations, while also highlighting the overall increasing trend in the utilization of family planning, HIV counselling and testing, and maternal and newborn care services from 2015 to 2020.

Socio-Cultural Factors Associated with RH Services Utilization

Bivariable and multivariable logistic regression analyses were conducted to assess the relationship between various factors and the uptake/utilization of reproductive health services. The results indicated significant associations. Firstly, there was a statistically significant relationship between the age of the respondent and reproductive health service utilization (p-value = 0.049). The odds ratio of 0.571 suggested a negative association, signifying that with each unit increase in the respondent's age, the odds of utilizing reproductive health services decreased by a factor of 0.571. The 95% confidence interval ranged from 0.327 to 0.997, including the value 1, indicating some variability in the data but still supporting the tendency for lower utilization with increasing age.

Secondly, a significant relationship was found between the place of residence (urban or rural) and reproductive health service utilization (p-value = 0.046). The odds ratio of 2.000 indicated that individuals in urban areas had twice the odds of utilizing reproductive health services compared to their rural counterparts. The 95% confidence interval ranged from 1.012 to 3.950, not including the value 1, which reinforced the significance of this association.

Lastly, there was a highly significant relationship between education status and reproductive health service utilization (p-value = 0.000). The odds ratio of 0.223 highlighted those individuals with higher education levels had 0.223 times lower odds of utilizing reproductive health services than those with lower education levels. The 95% confidence interval ranged from 0.223 to 0.406, excluding the value 1, further emphasizing the significance of this educational factor in relation to reproductive health service utilization.

Table 2: Socio-cultural factors associated with RH services utilization among women of reproductive age in South Sudan

Variables

User of RH services

n (%)

n = 290

Non-user of RH services

n (%)

n = 110

OR

(95% CI)

P Value

State 

       

Central Equatoria

173 (59.7)

59 (53.6)

1

 

Western Equatoria

117 (40.3)

51 (46.4)

1.197 (0.725-1.976)

0.482

Age 

       

Younger than 30 years

132 (45.5)

54 (49.1)

1

 

30 years and older

158 (54.5)

56 (50.9)

0.571 (0.327-0.997)

0.049*

Marital status

       

Married

186 (75.3)

82 (79.6)

1

 

Single

61 (24.7)

21(20.4)

0.858 (0.437-1.685)

0.657

Place of residence

       

Urban

60 (20.7)

14 (12.7)

1

 

Rural

230 (79.3)

96 (87.3)

2.000 (1.012-3.950)

0.046*

Employment status 

       

Not employed

176 (60.7)

84 (76.4)

1

 

Employed

114 (30,3)

26 (23.6)

0.631 (0.360-1.104)

0.107

Religion 

       

Christian

245 (84.5)

103 (93.6)

1

 

Traditional

45 (15.5)

7 (6.4)

0.617 (0.242-1.572)

0.311

Education status

       

No school/non-formal/dropped-out

138 (47.6)

89 (80.9)

1

 

Completed secondary

152 (52.4)

21(19.1)

0.223 (0.122-0.406)

0.000**

Source: Research Data (2023)

**. Correlation is significant at the 0.01 level

*. Correlation is significant at the 0.05 level

In summary, the research findings regarding socio-cultural factors influencing the uptake and utilization of reproductive health services indicate the following: older age is associated with a decreased likelihood of utilizing reproductive health services; individuals residing in urban areas have higher odds of utilizing reproductive health services compared to those in rural areas; and higher education levels are associated with lower odds of utilizing reproductive health services. These findings suggest that addressing socio-cultural factors such as age, place of residence, and education status is crucial in promoting and improving the uptake and utilization of reproductive health services in the context of South Sudan.

Discussion

The research findings related to the uptake and utilization of Reproductive Health Services (RHS) in selected South Sudan public health facilities were analyzed within the conceptual frameworks of the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These models provide essential insights into the factors influencing individuals' decisions regarding RHS utilization.

In this study, the HBM was employed to investigate the determinants of RHS utilization. The HBM encompasses key constructs, such as perceived susceptibility and severity, perceived benefits, perceived barriers, and cues to action, to understand how people perceive and make decisions about their health behaviours. Findings from the study indicate that perceived susceptibility and severity of RH issues are crucial in motivating individuals to engage in RH behaviours. Perceived susceptibility varies among individuals, underscoring the importance of threat perception. The perceived severity is influenced by factors including emotional responses and cognitive assessments of health problems, encompassing medical complications and broader consequences on individuals' lives. Additionally, the study highlights those perceived benefits significantly influence individuals to take action in preventing RH threats. When individuals believe that RHS are effective in addressing their health concerns, they are more likely to utilize these services. Moreover, the study underscores the role of "cues to action" as triggers for health behaviour, including physical symptoms, mass media communications, interpersonal interactions, advice from others, health education campaigns, and reminders from healthcare providers. These cues play a substantial role in motivating individuals to access RHS.

In parallel, the TRA provides insights into the role of attitudes, subjective norms, and intentions in predicting health-related behaviours. The study findings demonstrated that attitudes toward RHS significantly correlated with beliefs and outcome evaluations related to these services. The stronger an individual's intention to use RHS, the more likely they are to engage in the behaviour. Attitudes and subjective norms were identified as significant determinants of the intention to utilize RHS. These results highlight the importance of shaping positive attitudes toward RHS and considering the influence of social norms and peer opinions when designing interventions to promote RHS utilization.

Level of Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities

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.

Socio-Cultural Factors Associated with RH Services Utilization

The study revealed that the majority of the respondents (53.5%) were 30 years and older, while the remaining 46.5% were younger than 30 years. The statistical analysis showed a significant relationship between the age of the respondents and the uptake and utilization of RHS. The p-value of 0.049 suggests that age is a contributing factor in determining the utilization of these services. A study conducted in Kenya by Kinaro et al. (2019) found that early marriage, being young, male-only decisions on sexuality matters and fear of family contribute to unprotected sex while myths and misconceptions on contraceptives affected the utilization of RHS. Another study conducted in Kenya by Godia et al. (2014) found that most youths are not aware of existing RHS. They found that young people’s perception and knowledge of younger girls (12–14 years) is limited with a majority reporting that they don’t know much about RHS. This current finding implies that older women are less likely to utilize RHS compared to younger women. Possible reasons for this could include cultural norms, lack of awareness, or different reproductive health needs at different stages of life.

The study found that over 80% of the respondents resided in rural areas, while the remaining 18.5% lived in urban regions. The analysis demonstrated a statistically significant relationship between the place of residence and the uptake and utilization of RHS. The p-value of 0.046 indicates that the place of residence plays a role in determining the utilization of these services. A previous study conducted by Sumankuuro et al. (2018) shared similar findings, they found that women from rural (or poverty-stricken) areas are vulnerable because of their status and lack of access to RH services. Their risk behaviors as well as their access to RH services are influenced significantly by the type of place that they reside. The current study established that individuals residing in urban areas have twice the odds of utilizing RHS compared to those in rural areas. This could be attributed to better access to healthcare facilities, increased availability of services, and potentially higher levels of education and awareness in urban settings.

The study showed that the educational level of the respondents is significantly related to the uptake and utilization of RHS. The p-value of 0.000 indicates a highly significant relationship between education status and service utilization. This finding contradicted other studies (Aragie and Abate, 2021; Abebe and Awoke, 2014), which stipulated that those families with higher educational status are more likely to be familiar with RHS-related issues. However, this study indicates that individuals with higher education levels have 0.223 times lower odds of utilizing RHS compared to those with lower education levels. This finding may seem counterintuitive, as higher education is often associated with better access to information and resources. However, it's important to consider other factors such as socioeconomic status, cultural beliefs, and personal preferences that may influence the relationship between education and service utilization.

Overall, the findings suggest that age, place of residence, and education status are significant socio-cultural factors influencing the uptake and utilization of RHS among women in South Sudan. These findings highlight the need for targeted interventions and strategies to address barriers and promote RHS among older women, rural populations, and individuals with lower levels of education. Improving access to healthcare facilities, increasing awareness about available services, and addressing cultural norms and beliefs are crucial steps toward enhancing reproductive healthcare utilization and ultimately improving the well-being of women in South Sudan.

Conclusions

The study revealed that perceived susceptibility and severity of RH issues significantly motivate individuals to engage in RH behaviours. The perceived benefits of utilizing RHS play a pivotal role in encouraging individuals to take action to prevent RH threats. Additionally, the study emphasized the importance of "cues to action" as mechanisms to trigger health behaviour, including physical symptoms, mass media communications, interpersonal interactions, advice from others, health education campaigns, and reminders from healthcare providers. These cues significantly motivated individuals to access reproductive health services.

The findings also demonstrated that age, place of residence, and education status are crucial socio-cultural factors influencing the uptake and utilization of RHS. Older women were less likely to utilize these services compared to younger women, which may be attributed to cultural norms, varying RH needs at different life stages, or a lack of awareness. Urban residents were found to have higher odds of utilizing RHS, potentially due to better access to healthcare facilities, increased service availability, and higher levels of education and awareness. Surprisingly, individuals with higher education levels exhibited lower odds of utilizing RHS, emphasizing the complex interplay of socioeconomic status, cultural beliefs, and personal preferences in the relationship between education and service utilization.

The study's findings hold significant implications for policy, practice, and future research in the field of RHS. First and foremost, enhancing public awareness campaigns is crucial to ensure women are well-informed about the availability and accessibility of RHS. These campaigns should be tailored to address the diverse needs and perceptions of both urban and rural populations. Second, improving service delivery is imperative to bridge the existing gap in comprehensive RHS availability. This entails expanding the range of services offered by public health facilities, extending beyond family planning and STI management to encompass maternal and newborn care and HIV counselling and testing. Lastly, the study underscores the importance of implementing targeted interventions to overcome barriers faced by specific demographic groups, including older women, rural residents, and individuals with lower educational attainment. These interventions should take into account the influence of cultural norms, socioeconomic factors, and individual preferences to effectively promote the utilization of RHS services.

The study presents several limitations that warrant consideration. First, it is essential to acknowledge that the research centred on two specific states within South Sudan, potentially limiting the generalizability of the findings to the broader national context. Furthermore, the cross-sectional design employed in this study offers a snapshot of the observed relationships, but it does not permit the establishment of causal relationships. Lastly, the data collection relied on self-reporting, which may introduce biases related to recall and social desirability. 

Future research should aim to expand the geographical scope to include a more representative sample of South Sudan. Longitudinal studies can provide more robust insights into trends and causal relationships regarding RHS utilization. Furthermore, exploring the influence of other socio-cultural factors, such as socioeconomic status, cultural beliefs, and access to healthcare facilities, will provide a more comprehensive understanding of the determinants of RHS utilization in South Sudan. Additionally, comparative studies between different theoretical frameworks, such as the HBM and TRA, can offer insights into which model best explains RH behaviours in this context. These avenues of research can contribute to a more holistic approach to addressing RH challenges in South Sudan and similar settings.

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.

References

  1. Abebe, M., & Awoke, W. (2014). Utilization of Youth Reproductive Health Services and Associated Factors among High School Students in Bahir Dar, Amhara Regional State, Ethiopia. Open Journal of Epidemiology, 4, 69-75. https://doi.org/10.4236/ojepi.2014.42012
  2. Aragie, T. G., & Abate, B. B. (2021). Utilization of Reproductive Health Services and Associated Factors among Secondary School Students in Woldia Town, Northeast Ethiopia. J Environ Public Health, 2021, 2917874. https://doi.org/10.1155/2021/2917874
  3. Guttmacher Institute. (2017). Fact Sheet: Abortion in Asia. https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-asia_0.pdf
  4. Integrity. (2018). Evaluation of the South Sudan Health Pooled Fund.
  5. IPC. (2018). Integrated food security phase classification, The Republic of South Sudan: Key findings.
  6. Kane, S., Kok, M., Rial, M., Matere, A., Dieleman, M., & Broerse, J. E. (2016). Social norms and family planning decisions in South Sudan. BMC Public Health, 16(1), 1–12. https://doi.org/10.1186/s12889-016-3839-6
  7. Kinaro, J. W., Wangalwa, G., Karanja, S., Adika, B., Lengewa, C., & Masitsa, P. (2019). Socio-Cultural Barriers Influencing Utilization of Sexual and Reproductive Health (SRH) Information and Services among Adolescents and Youth 10 - 24 Years in Pastoral Communities in Kenya. Advances in Sexual Medicine, 9, 1–16. https://doi.org/10.4236/asm.2019.91001
  8. Larson, G., Ajak, P., & Pritchett, L. (2013). South Sudan’s Capability Trap: Building a State with Disruptive Innovation; 2013.
  9. Ministry of Health. (2012). Health Sector Development Plan 2012-2016.
  10. Sumankuuro, J., Crockett, J., & Wang, S. (2018). Sociocultural barriers to maternity services delivery: a qualitative meta-synthesis of the literature. Public Health, 157, 77–85.
  11. UNICEF. (2016). The State of the World’s Children 2016: a fair chance for every child. https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-020-09155-w.pdf
  12. UNICEF. (2021). Child Marriage: South Asia. https://www.unicef.org/rosa/what-we-do/child-protection/child-marriage
  13. UNPF. (2012). Promises to Keep. https://www.unfpa.org/sites/default/files/pub-pdf/AR%202012%20EN-Final.pdf
  14. UNPF. (2019). Sexual and Reproductive Health and Rights: An Essential Element of Universal Health Coverage. https://www.unfpa.org/sites/default/files/pub-pdf/SRHR_an_essential_element_of_UHC_SupplementAndUniversalAccess_27-online.pdf
  15. United Nations. (2015). Trends in contraceptive use worldwide 2015.
  16. United Nations. (2019). Estimates and Projections of Family Planning Indicators.
  17. WHO. (2021). Reproductive health. https://www.who.int/westernpacific/health-topics/reproductive-health
  18. WHO Africa. (2020). Sexual and Reproductive Health Fact Sheet.
  19. WHO Africa. (2021). Sexual and Reproductive Health. https://www.afro.who.int/health-topics/sexual-and-reproductive-health
  20. WHO Europe. (2020). HIV/AIDS surveillance in Europe.
  21. WHO Europe. (2021). Sexual and Reproductive Health. https://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/sexual-and-reproductive-health
  22. World Bank. (2018). World Development Indicators. http://databank.worldbank.org/data/source/healthnutrition-and-population-statistics