Despite the relative decline in the overall adolescent birth rate worldwide, from 56 births per 1,000 women aged 15–19 in 2000 to 44 per 1,000 in 2018, it remains high (101 per 1,000) in sub-Saharan Africa (1).

Thus, reducing the frequency of pregnancies among adolescents and young people is becoming a priority in sub-Saharan Africa, where frequent complications related to unwanted pregnancies (2, 3). In this context, although the provision of family planning (FP) services is guided by the principle of informed client choice, a number of barriers limit their availability and use (4, 5). These barriers partially sustained high unmet needs, particularly among adolescents and youth in sub-Saharan Africa contexts (4–6).

In Guinea, half the population is under 24 years. However, in 2018, more than a third (38%) of sexually active adolescent and young unmarried women aged 15–24 had an unmet need for FP (7). The existence of the unmet need for FP can result from factors including lack of delivery of services (e.g., low coverage or quality of FP services, attitudes, and practices of providers) or demand (Knowledge of FP, socio-cultural norms, access to services, etc.) (8, 9). For example, certain socio-cultural norms or individual considerations may influence health care providers' attitudes that limit adolescents' and youths' access to and use of sexual and reproductive health services (10). Thus, provider attitudes and communication problems, real or perceived, may contribute to the unmet needs for contraception (2, 11).

In addition, several studies in Africa have found that providers have restrictive practices or attitudes toward the delivery of contraceptive services to adolescents and youth (12–15). In this context, non-marital sexual relations are very poorly perceived by some health providers, leading to negative attitudes on their part in providing FP services to unmarried young women (12, 16). Other providers reported feeling very uncomfortable or reluctant about delivering a modern contraceptive method to adolescents and youth because of their young age (6, 17). In Senegal, a study examined the role of provider restrictions on young women's access to and use of contraception. These biases and provider restrictions contributed to youth's lack of access to contraception (18).

Furthermore, the perception that contraceptive use can lead to infertility or that it represents a practice contrary to religious belief justifies the negative attitude of some providers (19, 20). Moreover, providers' lack of knowledge about the eligibility criteria for modern contraceptive methods among adolescents and youth encourages irregular prescription of contraceptives (21).

However, favorable attitudes toward contraception among youth were most likely to be found among health providers with more education or those who had received sufficient continuing education on adolescent sexuality and reproductive health (16, 20, 22). Thus, health providers need sufficient knowledge and a positive attitude toward adolescent contraceptive users to better play their role in prescribing contraceptives to prevent unplanned pregnancies among adolescents and young women (21).

Although the various studies mentioned above examine the attitudes and perceptions of providers in delivering family planning services to adolescents and young women, certain aspects remain little studied, for example, the specific factors that influence providers' practice in urban areas.

Systematic analysis of the factors associated with the attitudes and practices of these providers would generate useful information for improving contraceptive use in this target population. In addition, it would help to address the challenges that are slowing down the repositioning of FP and the promotion of sexual and reproductive health among adolescents and youth in urban areas (23, 24).

The objective of this study was to analyze providers' knowledge, attitudes, and practices (KAP) regarding access to and use of contraceptive methods by adolescents and youth in urban areas. Specifically, it describes the KAPs and analyzes the factors associated with providers' attitudes and practices.

This study is one of the first to explore FP providers' knowledge, attitudes, and practices with regard to adolescents and youth and their determinants in Guinea.

The data from the survey of providers' attitudes and practices regarding the provision of FP counseling and services to adolescents and youth revealed a degree of tension between personal moral beliefs and perceived obligation or duty to provide services. Substantial minorities (close to 40%) of providers thought that teenagers and unmarried youth should abstain from sex and that contraceptive use by them was immoral and contrary to religious beliefs and cultural norms. A majority thought that provision of contraception would only encourage sexuality. Yet close to 90% were aware of the right of young people to receive family planning advice and services and over 80% agreed that health personnel should provide contraceptive services to unmarried as well as married young people. Similar high proportions expressed confidence in counseling and service provision to young people and only 15% admitted that they sometimes or often scolded young people when they requested contraceptives.

Interpretation of these findings should be cautious because of the danger that responses may have been influenced by social desirability bias. Yet it does appear probable that most providers with moralistic reservations about premarital sex and contraception do manage to put aside their personal feelings when confronted by young people requesting FP advice and services. This verdict is supported by results from the 2018 DHS in which over 40% of sexually active single women aged 15–24 reported use of injectable or implants (7), both methods that require a visit to a health facility and attention from a trained provider.”

Factors simultaneously associated with positive attitudes and good practices among providers in this study included socio-professional category, number of years of experience in delivering contraceptive services, and region of residence. In addition, provider age was associated with positive provider attitudes in delivering modern methods to adolescents and youth.

About four out of five health care providers were aware of national policies and rights regarding provision of modern contraceptive use among adolescents and youth. The majority (83.7%) reported being confident in explaining the mode, duration of action, advantages, and disadvantages of contraceptive methods to adolescents and youth. Our results are consistent with those of Tshitenge et al. (21) in Botswana, who found that 91.2% of providers felt confident in explaining to adolescents how to use contraceptive methods. There are several possible explanations for this result. In recent years, considerable efforts have been made to improve the availability and use of contraceptive methods by the population, particularly adolescents and youth. For example, the national FP repositioning plan (2014–2018) aimed, among other things, to stimulate the delivery of FP services in all health facilities, including private ones; as well as to strengthen the training program and the equipment of private and public health facilities (27). The effects of these strategies, including the repositioning plan, could explain the level of knowledge of the providers interviewed in our study. In addition, most of the providers interviewed aged were less than 35 years and had a qualifying medical education. This could also explain their good level of knowledge and confidence in explaining the mode, duration of action, advantages, and disadvantages of contraceptive methods to adolescents and youth.

Even most providers had a positive attitude toward the use of modern contraceptive methods by adolescents and youth, some of them had social considerations that might influence their practices in providing FP services to adolescents and youth. Other studies have also revealed the presence of important contextual and social norms that lead to health providers negative attitudes toward the delivery of modern method contraceptive services to adolescents and youth (12, 13, 15–17, 21).

More than one-third (39%) of the providers felt that unmarried youth should not receive contraceptives because their culture does not support premarital sex. Nearly one out of four providers felt that it was immoral for adolescents and youth to use contraceptives. These results corroborate the findings of Nalwadda et al. in Uganda and Ahanonu in Nigeria, who reported that more than one-third of maternal and reproductive health providers said they would not provide contraceptives to unmarried, school-going, and childless people under age 18 because of social norms (12, 17). Health care providers may believe that they owe adolescents and unmarried youth a duty to protect them from sexual practice. However, this perception does not match reality, as evidenced by the high rates of sexual activity, sexually transmitted infections, and unwanted pregnancies and their implication for school dropout among this group. This negative attitude of health care providers is a major challenge to national efforts to ensure young people's right to sexual health, to protect their lives and their future. Positive attitudes among health care providers are a key element in improving contraceptive use among adolescents and youth. It is important that attitudes against contraceptive use by sexually active adolescents and youth be revised to reflect the realities of their sexuality. For example, sexual abstinence should be encouraged by providers for those adolescents and youth who are ready to practice it. For those who are sexually active and want to use contraceptives, access to contraceptive services should not be confronted with religious considerations, as it is better to prevent unwanted pregnancies and STIs than to face the consequences that may result. Only two in five providers had good practices regarding contraceptive use by adolescents and youth. This result is similar to those of other authors in Uganda (17, 28). This result could be explained by the persistence of the weight of socio-cultural factors such as religious beliefs on health care providers in delivering FP services.

Our results showed that being a midwife, having several years of professional experience, and residing in the Lower, Upper, middle, and Forest Guinea regions were simultaneously associated with positive attitudes and good provider practices toward modern contraceptive use by adolescents and youth. This result corroborates that of other authors in Nigeria (12) and in South Africa (29, 30) who argue that providers' region of residence, socio-professional category, and years of experience influence their attitudes and practices toward delivering FP services to adolescents. The simultaneous association of professional experience with positive attitudes and good practices could be explained by the acquisition of skills and confidence over the years in providing health services to adolescents and youth. The association of midwifery with positive attitudes and good practices regarding the use of modern contraceptive methods by adolescents and youth is explained by the frequent exposure of this group of providers to training on sexual and reproductive health issues, including among adolescents and youth.

The study also showed that the likelihood of having positive attitudes toward the use of modern contraceptive methods by adolescents and youth increased with provider age. This finding supports our initial observations of a positive relationship between increasing years of work experience and positive provider attitudes. It also corroborates the findings of Jonas et al. in South Africa, who found a positive association between the number of years of experience of health workers and their likelihood of providing maternal and child health services to adolescents (30). This result can be explained by the fact that the older the health worker, the more he or she is exposed to realities that influence his or her perceptions of adolescent contraception.

Our study also finds a positive association between gender, midwives' socio-professional category, and a positive provider attitude. Our results are consistent with those of Jonas et al. in South Africa, who found that years of experience as a nurse or midwife were associated with stronger intentions to provide FP services to adolescents (30). Furthermore, midwives are the ones most involved in the provision of contraceptive methods and therefore are exposed over time to training and work experience that improves their practices. Another explanation for the association between female gender and a positive provider attitude may be that women are more predisposed to understanding the needs of adolescents for birth control once they are sexually active, particularly when they are unmarried.

In addition, providers living in the countryside had better attitudes toward using modern contraceptive methods by adolescents and youth than providers in Conakry. The reason for this funding remained speculative. One possible reason is that health system actors put substantial efforts in improving health indicators in rural and remote areas, thereby neglecting health personnel capacity-building needs in the Capital. Further studies are needed to understand the underlying reasons for this finding.

Our results also showed that being a medical doctor and having several years of professional experience were significantly associated with provider practices in delivering modern methods to adolescents and youth. Medical doctors were also more likely to have good practices regarding the use of contraceptive methods by adolescents. This would be especially important if they are involved in providing reproductive health services in general. Our result would be explained by the fact that medical doctors are the ones who face the most serious consequences of adolescents' unmet need for contraception, such as complications from clandestine abortion. Paul et al. (30) in Uganda found that, beyond considerations for existing socio-cultural values of chastity, health personnel involved in delivering FP services had a better understanding of the vulnerability of girls and the consequences of adolescent pregnancy, and especially when they are unmarried.

Knowledge, attitudes, and practices of health care providers affect the delivery of FP services to adolescents and youth in Guinea. Most health care providers were confident in explaining their use, advantages, and disadvantages to adolescents and youth. However, a disparity exists between the level of Knowledge of health care providers and their attitudes and practices toward delivering FP services to adolescents and youth. Factors concurrently associated with positive attitudes and good practices of providers in this study included socio-professional category, number of years of experience in delivering contraceptive services, and region of residence. Future intervention programs should focus on training health care providers in youth- and adolescent-friendly reproductive health services and on popularizing regulations for adolescent contraception. This intervention should also include developing and implementing a continuing education program on the provision of contraceptive services for health providers who are nurses and midwives and have less than two years of experience in contraceptive provision. Additional efforts will also be needed to improve the attitudes and practices of health care providers toward the delivery of FP services in Guinea. Health care providers' attitudes should be based on the sexual realities of adolescents and youth. Further studies are needed to understand the underlying reasons for the health providers attitudes toward using modern contraceptive methods by adolescents and youth.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by National Committee of Ethics for Health Research in Guinea (No: 045/CNERS/19). Written informed consent to participate in this study was provided by the participants prior to participating in the study.

SS, AD, DK, BSC, and SK designed the study and developed the study protocol. SS, FMG, and AD designed the analysis plan. SS, DK, and FMG, performed the data analyses, interpreted the results, and the manuscript was drafted by SS with critical inputs from DK, SK, BSC, and AD. All authors critically revised and approved the final manuscript.

This research was part of a research scholarship provided by the International Union for the Scientific Study of Population (IUSSP) through the Grant No. OPP1179495 from the Bill & Melinda Gates Foundation. Additional funding to the lead author was provided by HRP. Alliance, part of The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO), through a PhD Scholarship granted by Institut Africain de Santé Publique (IASP/USTA) of the Université Saint Thomas D'Aquin, Burkina Faso. This article represents the views of the named authors only and does not represent the views of the World Health Organization.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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