Background: Many Adolescents in Sub-Saharan Africa do not access HIV and reproductive health services optimally. To improve uptake of these services, it is important to understand the Learners' preferences for how services are delivered so that implementation strategies can reflect this. Methods: A discrete choice experiment (DCE) was used to elicit preferences. The DCE was completed between 07/2018 and 09/2019 and conducted in 10 high schools situated in neighbourhoods of varying socio-economic status (SES) in Gauteng (South Africa). Learners aged ≥ 15 years (Grades 9–12) were consented and enrolled in the DCE. Parental consent and assent were required if < 18 years old. Conditional logistic regression was used to determine preferred attributes for HIV and contraceptive service delivery. Results were stratified by gender and neighbourhood SES quintile (1 = Lowest SES; 5 = Highest SES). Results: 805 Learners were enrolled (67% female; 66% 15–17 years; 51% in grades 9–10). 54% of Learners in quintile 1 schools had no monthly income (family support, grants, part-time jobs etc.); 38% in quintile 5 schools had access to R100 ($7.55) per month. Preferences for accessing HIV and contraceptive services were similar for male and female Learners. Learners strongly preferred services provided by friendly, non-judgmental staff (Odds ratio 1.63; 95% Confidence Interval: 1.55–1.72) where confidentiality was ensured (1.33; 1.26–1.40). They preferred services offered after school (1.14; 1.04–1.25) with value-added services like free Wi-Fi (1.19; 1.07–1.32), food (1.23; 1.11–1.37) and youth-only waiting areas (1.18; 1.07–1.32). Learners did not have a specific location preference, but preferred not to receive services within the community (0.82; 0.74–0.91) or school (0.88; 0.80–0.96). Costs to access services were a deterrent for most Learners irrespective of school neighbourhood; female Learners were deterred by costs ≥$3.85 (0.79; 0.70–0.91); males by costs ≥ R100 ($7.55) (0.86; 0.74-1.00). Conclusions: Preferences that encourage utilisation of services do not significantly differ by gender or school neighbourhood SES. Staff attitude and confidentiality are key issues affecting Learners' decisions to access HIV and contraceptive services. Addressing how healthcare providers respond to young people seeking sexual and reproductive health services is critical for improving adolescents' uptake of these services.
Keywords: Discrete choice experiment; South Africa; HIV; Contraceptive; Adolescent; Schools
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1186/s12913-023-10414-w.
Poor reproductive health outcomes among adolescents remain a public health concern in sub-Saharan Africa. Many young people continue to face challenges associated with sexually transmitted infections, including HIV as well as unintended pregnancies [[
South Africa has made a host of essential sexual and reproductive health (SRH) services available to adolescents. To facilitate this, South Africa created a legal framework that allows adolescents to access these services including HIV testing, and most recently PrEP [[
Despite these efforts, youth's utilization of HIV and contraceptive services remains low [[
We aim to address this gap in the literature by eliciting the preferences of school going adolescents, ≥ 15 years, in Johannesburg, (Gauteng, South Africa) for the delivery of HIV and SRH services. This will provide South African policy makers with insights into Learner preferences and quantify the strength of those preferences for these services in order to improve the uptake of these services.
We conducted a discrete choice experiment (DCE) to determine the preferences of school going adolescents with respect to accessing SRH services. A DCE is a quantitative method used to elicit individuals' preferences for certain choice sets by examining the trade-offs that individuals make between the tangible and intangible attributes of goods and services [[
To identify attributes of SRH service delivery models that are important to Learners we conducted a literature review and qualitative research (focus group discussions (FGD) and stakeholder interviews). The literature review informed the development of research tools for the FGDs and interviews. We conducted FGDs with Learners to establish their experiences and opinions of SRH service delivery. This was supplemented with interviews from key stakeholders (principals, teachers, parents, representatives of DBE and DOH). Based on the qualitative work, we generated an exhaustive list of service delivery attributes that school-going adolescents found important for decision-making. It is good practice to limit attributes for inclusion in the DCE survey to avoid decision fatigue, maximize comprehension and reduce survey completion time [[
Of the eight attributes included in the DCE, six had four levels and two had two levels, resulting in 16,384 possible combinations (4 × 4 × 4 × 4 × 4 × 4 × 2 × 2). As it is not feasible to directly compare each possible combination we developed a fractional factorial design that was highly efficient, balanced and orthogonal, with a relative D-efficiency of 94% using SPSS version 25.0 [[
The population of interest was defined as South African school-going learners ≥ 15 years old in Gauteng Province. The study was conducted at ten purposively selected schools in Gauteng situated in low to moderate socioeconomic settings (SES) across all wealth quintiles 1–5 and areas with high HIV prevalence and/or high teenage pregnancy rates (as reported by the Department of Basic Education). We selected schools based on the need for improved access to HIV and contraceptive services, using Gauteng Department of Education statistics, 2017/2018 District Health Barometer reports, and pupil pregnancy rates. We focused on schools with 1,000 + pupils. Schools were selected from Johannesburg east [[
Study staff, with the help of school staff, went to all grade 9–12 classes at the selected schools to provide information on the study and all eligible Learners (≥ 15 years) were invited to participate, and given informed consent documentation to take home. Younger Learners (< 18 years) provided assent with parental consent, while older Learners (≥ 18 years) were able to provide their own informed consent. Signed consent documentation was collected from the schools at separate visits. On the day of the DCE, Learners were cross checked against a register to ensure that only consented Learners participated. Surveys took place in dedicated class rooms and 20–50 Learners participated simultaneously. Figure 1 shows an example of a choice task. Each Learner was randomly assigned a DCE booklet (4 different blocks) with a corresponding answer sheet. Learners self-administered the survey by shading in the correct answer on the answer sheet which had a unique identifier which could not be linked to the individual Learners. Data were extracted by scanning the answer sheets using Remark Office OMR software [[
The study protocol was reviewed and approved by the Human Research Ethics Committee (Medical) (#170213) of the University of the Witwatersrand (HREC) and the Boston University Medical Campus Institutional Review Board (H-35987) of the Boston University School of Public Health. All participants provided written informed consent to participate in the study.
Graph: Fig. 1Example of choice set
There were two primary data sets obtained from each participant: (a) demographic characteristics and (b) the results of the discrete experiment.
Descriptive statistics were used to summarize demographics. We summarized baseline characteristics for each group as medians with interquartile ranges (IQR) and proportions.
We used a conditional logit model to determine the relationship between each level of an attribute and the choice that the participant made [[
In outlining this study presentation, we have considered the ten items of the checklist for conjoint analysis in healthcare as described by Bridges et al. [[
The DCE was carried out in ten schools and a total of 2,245 consent forms were given out. Most forms (59%) were given to female Learners and 1,068 (47%) were signed and returned. 805 (75%) of those who provided consent attended the DCE. The reasons for not attending were not recorded. Figure a2 in the Appendix 1 illustrates the flow of enrolments from consent to participation.
Table 1 presents the demographic characteristics for the 805 Learners who completed the survey. Over two thirds (67%) of the participants were female. Around two thirds 530 (65.8%) of those Learners who participated were aged 15–17 years, the remainder 272 (33.79%) being aged 18 years and over.
Table 1 Summary of demographics characteristics among learners
Characteristic Level Age 15–17 years 530 (65.84%) 18 and older 272 (33.79%) Missing 3 (0.37%) Gender Female 534 (66.34%) Male 259 (32.17%) Other 8 (0.99%) Missing 4 (0.50%) Monthly Income No income 351 (43.60%) R10-50 ($ 1–4) 168 (20.87%) R51-100 ($ 4–7) 102 (12.67%) More than R100 ($ 7) 179 (22.24%) Missing 5 (0.62%)
Table 2 Shows participant characteristics in relation to their sexual behaviour and service access. A total of 390 (49%) Learners reported that they were sexually active. Among those sexually active, 54% were female. Interestingly, a higher proportion of male participants (68%) reported being sexually active compared to female participants (39%). Among those reporting that they were sexually active, slightly less than half 185 (48%) reported that they had had an HIV test in the 12 months preceding the survey.
Table 2 HIV and contraceptive utilisation among Learners who have never had sex and those who have had sex
Characteristic Level Ever had sex Never had sex Accessed services in last 12 months No 259 (66.93%) 355 (85.75%) Contraceptive service 45 (11.63%) 13 (3.14%) HIV services only 47 (12.14%) 39 (9.42%) HIV and contraceptive 32 (8.274%) 1 (0.24%) Missing 4 (1.03%) 6 (1.45%) Ever had HCT No 91 (23.51%) 199 (48.07%) Yes 292 (75.45%) 215 (51.93%) Missing 4 (1.00%) 0 (0.00%) HCT in last 12 months No 201 (51.94%) 289 (69.80%) Yes 185 (47.80%) 121 (29.23%) Missing 1(0.26%) 4 (0.97%)
Figure 2 shows the model for all Learners. There was a preference for friendly health care providers (OR 1.63; 95% CI 1.55–1.72) and confidential services (OR 1.33; 95% CI 1.26–1.40). Provision of services outside of traditional clinics, such as in the community (OR: 0.82; 95% CI 0.74–0.91) or in school (OR 0.88; 95% CI 0.80–0.96), was a deterrent. Learners preferred accessing services in the afternoon (OR 1.14; 95% CI 1.04–1.25) compared to in the morning. They were indifferent to the provider demographics, in terms of their age or where they were from. Any value-added service, such as youth only waiting areas (OR 1.13; 95% CI 1.03–1.24), Wi-Fi (OR 1.19; 95% CI 1.07–1.32), and access to food (OR 1.18; 95% CI 1.07–1.29), increased odds of choosing a service. Learners preferred the more comprehensive package of services (family planning and contraceptive services) (OR 1.17; 95% CI 1.07–1.28) with integrated health services (OR 1.12; 95% CI 1.02–1.23) as opposed to receiving condoms or HCT only. Cost only became a deterrent to accessing services at R100 ($3.85) and above (OR = 0.84; 95% CI 0.76–0.93).
Graph: Fig. 2Conditional logistic regression model results for discrete choice experiment eliciting learner preferences for HIV and contraceptive service provision (all learners)
Figure 3 shows the DCE results stratified by gender. Female Learners preferred services to be provided in the afternoon (OR: 1.15; 95% CI 1.03–1.28) whereas male Learners showed no real time preference. Female Learners in particular had a strong preference for providers with a friendly attitude (OR: 1.72; 95% CI 1.61–1.84) more so than males (OR: 1.48; 95% CI 1.35–1.61). The cost of accessing services became a deterrent for girls at R50 ($3.77) (OR:0.79; 95% CI 0.70–0.90) whilst for males cost only became a deterrent where it was above R100 ($7.55) (OR: 0.86; 95% CI 0.74-1.00).
Graph: Fig. 3Conditional logistic regression model results for DCE eliciting learner preferences for HIV and contraceptive service provision (by gender). HCP: Health care provider// FP: Family planning// HCT: HIV counselling and testing
Figure 4 shows the DCE results stratified by quintiles. Friendly attitude (OR: 1.62; 95% CI 1.52–1.73) for lower quintiles and (OR: 1.71; 95% CI 0.56–1.87) for upper quintile and confidential services (OR: 1.20; 95% CI 1.13–1.28) for lower and (OR: 1.60; 95% CI 1.46–1.75) for upper, remained the most important attributes across quintiles. Providing services outside of traditional clinics, such as in schools (OR: 0.80; 95% CI 0.69–0.94) or communities (OR: 0.71; 95%CI 0.59–0.85) was a deterrent among those in higher wealth quintiles but did not appear to be a deterrent in lower wealth quintiles. While availability of cheap food and youth only waiting areas remained as a preference across quintiles, free Wi-Fi was only important to Learners as an incentive for accessing these services in the lower quintiles (OR: 1.22; 95% CI 1.07–1.39). Learners in lower quintiles were willing to pay up-to R100 for services whilst higher quintiles had a lower willingness to pay (OR: 0.82; 95%CI 0.73–0.92) for > R100 ($7.55) vs. (OR: 0.72; 95%CI 0.60–0.86) for R51-100 ($ 3.85–7.55).
Graph: Fig. 4Conditional logistic regression model results for discrete choice experiment eliciting learner preferences for HIV and contraceptive service provision (stratified by SES)4HCP: Health care provider// FP: Family planning// HCT: HIV counselling and testing // Quintile: School categorisation for allocation of financial resources (1=Lowest SES; 5=Highest SES)
The DCE results indicate that friendliness, privacy and confidentiality are strong drivers of choice for adolescent use of SRH and HIV services. The importance of staff attitudes for increasing demand and utilization of services by Learners was consistent across socio-economic status and gender.
This aligns with results from other studies that report poor staff attitude and lack of confidentiality as main barriers to utilization of HIV and contraceptive services among different populations (youth included) [[
We constructed the DCE questionnaire to include an attribute on services available and varied the levels to indicate either individual services like HIV testing only or more comprehensive package of services that included contraceptive services, HIV testing and treatment. Learners, especially females preferred a more integrated service provision, that would include provision of HIV testing, STI management, contraception services and family planning services.
Previous literature has demonstrated that high rates of HIV and SRH service utilization among adolescents could be achieved by providing these HIV and SRH services within schools [[
Cost of care (transport, food, etc.) has been shown to be a major barrier to health utilisation among youths and adolescents [[
Facility operating hours are often barriers to utilization of services and "special" service hours may offer opportunity for more confidential services for those accessing services [[
A major finding in this study is that value added services like youth only waiting areas, cheap food and Wi-Fi could increase the odds of services being utilized. Interestingly, availability of Wi-Fi would be more likely to impact Learners from lower wealth quintile schools where they are less likely to have easy access to Wi-Fi in their homes or schools. However, it is also less likely that clinics in these areas have consistent internet access and so this network connectivity would need to be addressed before access to Wi-Fi is possible. The ISHP and the Adolescent SRH Policy in South Africa point to the need for "youth friendly" care [[
Few studies have looked at preferences for SRH and HIV services among adolescents using the DCE method [[
This study is one of few studies that have employed the use of a DCE among adolescents and specifically school-going adolescents. The use of extensive qualitative data to inform our DCE design gives us confidence in the design.
A potential limitation of the DCE is the cognitive burden on the participant as they have to think through many choice sets, which may result in inaccurate responses [[
The results may not be generalizable to other provinces, but we are confident that within Gauteng, the schools selected are representative of schools across the province. The study was conducted in 10 different schools, across 3 different wealth quintiles representing the socioeconomic status of the school neighbourhoods.
Our study focused on Learners aged 15 and above. It is important to investigate preferences of Learners between 12 and 15 years of age as they are by law allowed to access these services without parental consent. Unfortunately, this vulnerable population can often be hard to reach due to issues of consent and unintended disclosure.
While there are many interventions and programs that are aimed at providing services to young people in SA, effort needs to be geared towards making sure that young people are a first point of consultation when trying to understand their preferences for accessing health services. Addressing health system and structural issues to assist young people to easily access health services is also imperative. The results from this study quantified the preferences of Learners for accessing health services such as how health-care providers respond to young people seeking HIV-testing, contraceptives and sexual and reproductive health advice. If we are going to increase uptake of these services among adolescents it is critical that we address these issues. Adolescents must be able to access comprehensive, holistic HIV and SRH services at convenient times and value-added services like free Wi-Fi and youth only waiting areas may increase utilisation potentially by as much as 10 to 20%.
We would like to thank the Department of Basic Education, the educators and heads of school at the schools we conducted the research for their support and contribution to the success of the study.
CG, NLD, LL, SP and AM conceptualized and designed the study. CG conducted the analysis. CG prepared the original draft. CG, LL, NLD, AM, CM, NN, SMN and SP reviewed and edited the draft. All authors have read and approved the manuscript.
This study was made possible by the generous support of the American People and the President's Emergency Plan for AIDS Relief (PEPFAR) through US Agency for International Development (USAID) under the terms of Cooperative Agreements AID-674-A-12-00029 and 72067419CA00004 to Health Economics and Epidemiology Research Office. LL was supported by the National Institute of Mental Health of the National Institutes of Health under grant number K01MH119923. The contents are the responsibility of the authors and do not necessarily reflect the views of the NIH, PEPFAR, USAID or the United States Government. The funders had no role in the study design, collection, analysis and interpretation of the data, in manuscript preparation or the decision to publish.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
The study protocol was reviewed and approved by the Human Research Ethics Committee (Medical) (#170213) of the University of the Witwatersrand (HREC) and the Boston University Medical Campus Institutional Review Board (H-35987) of the Boston University School of Public Health. All participants provided written informed consent to participate in the study. All participants provided written informed consent to participate in the study. All participants less than 18 years of age provided assent with parental informed consent. All methods were performed in accordance with the relevant guidelines and regulations (e.g., Declaration of Helsinki).
Not applicable.
The authors declare no competing interests.
Graph: Additional file 1: Figure a1. Detailed description of DCE attributes and respective levels, Figure a2. Flow chart of participants for the DCE by school
Graph: Additional file 2.
• DCE
- Discrete choice experiment
• HIV
- Human Immunodeficiency Virus
• STIs
- Sexually transmitted infections
• SRH
- Sexual and Reproductive Health and Research
• HCT
- HIV voluntary counselling and testing
• IHSP
- Integrated School Health Policy
• SES
- Socioeconomic status
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