Original Study| Volume 34, ISSUE 4, P504-513, August 2021

Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana

Published:March 22, 2021DOI:


      Study Objective

      Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana.


      Cross-sectional mixed methods.


      Gaborone, Botswana.


      Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders.


      Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research.

      Main Outcome Measures

      Themes reflecting barriers and facilitators of LARC implementation.


      The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics’ inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs.


      We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric and Adolescent Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. World Health Organization: Adolescent pregnancy. Available: Accessed May 25, 2020.

      2. World Bank: Reproductive health at a glance: Botswana. Available: Accessed May 25, 2020.

      3. The World Factbook: Botswana. Available: Accessed May 26, 2020.

      4. World Bank: Adolescent fertility rate (births per 1,000 women ages 15-19). Available: Accessed May 25, 2020.

      5. Republic of Botswana Ministry of Basic Education: Second Botswana Youth Risk Behavioural and Biological Surveillance Survey report, Botswana, Ministry of Basic Education, 2016, pp 8-36.

        • Doherty K
        • Arena K
        • Wynn A
        • et al.
        Unintended pregnancy in Gaborone, Botswana: a cross-sectional study.
        Afr J Reprod Health. 2018; 22: 76
        • Santelli JS
        • Song X
        • Garbers S
        • et al.
        Global trends in adolescent fertility, 1990-2012, in relation to national wealth, income inequalities, and educational expenditures.
        J Adolesc Health. 2017; 60: 161
      6. Committee on Adolescence: Contraception for adolescents.
        Pediatrics. 2014; 134 (e1244)
      7. ACOG committee opinion no. 735 summary: adolescents and long-acting reversible contraception: implants and intrauterine devices.
        Obstet Gynecol. 2018; 131: 947
      8. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project: Family Planning: A Global Handbook for Providers (2018 update),Baltimore and Geneva, CCP and WHO, 2018, pp 131 - 210.

      9. United Nations Department of Economic and Social Affairs, Population Division: Trends in Contraceptive Use Worldwide, New York, United Nations, 2015, pp 1-63.

        • Hoque ME
        • Ntsipe T
        • Mokgatle-Nthabu M
        Awareness and practices of contraceptive use among university students in Botswana.
        SAHARA J. 2013; 10: 83
      10. Creswell JW Plano Clark VL Designing and Conducting Mixed Methods Research. SAGE Publications, California2007 (pp 62-79, 128-135)
        • Damschroder LJ
        • Aron DC
        • Keith RE
        • et al.
        Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
        Implement Sci. 2009; 4: 50
        • Harris PA
        • Taylor R
        • Thielke R
        • et al.
        Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377
        • Harris PA
        • Taylor R
        • Minor BL
        • et al.
        The REDCap consortium: building an international community of software platform partners.
        J Biomed Inform. 2019; 95103208
        • Weiner BJ
        • Lewis CC
        • Stanick C
        • et al.
        Psychometric assessment of three newly developed implementation outcome measures.
        Implement Sci. 2017; 12: 108
        • StataCorp
        Stata statistical software: release 16.
        StataCorp LLC, College Station, TX2019
        • Bradley EH
        • Curry LA
        • Devers KJ
        Qualitative data analysis for health services research: developing taxonomy, themes, and theory.
        Health Serv Res. 2007; 42: 1758
        • Hsieh HF
        • Shannon SE
        Three approaches to qualitative content analysis.
        Qual Health Res. 2005; 15: 1277
        • Wall KM
        • Bayingana R
        • Ingabire R
        • et al.
        Rwandan stakeholder perspectives of integrated family planning and HIV services.
        Int J Health Plann Manage. 2018; 33 (e1037)
        • Narasimhan M
        • Yeh PT
        • Haberlen S
        • et al.
        Integration of HIV testing services into family planning services: a systematic review.
        Reprod Health. 2019; 16: 61
        • Teklemariam E
        • Getachew S
        • Kassa S
        • et al.
        What works in family planning interventions in Sub-Saharan Africa: a scoping review.
        J Womens Health Care. 2019; 8: 2167
        • Rosenberg NE
        • Bhushan NL
        • Vansia D
        • et al.
        Comparing youth-friendly health services to the standard of care through “Girl Power-Malawi”: a quasi-experimental cohort study.
        J Acquir Immune Defic Syndr. 2018; 79: 458
        • Ngo TD
        • Nuccio O
        • Pereira SK
        • et al.
        Evaluating a LARC expansion program in 14 Sub-Saharan African countries: a service delivery model for meeting FP2020 goals.
        Matern Child Health J. 2017; 21: 1734
        • Adedini SA
        • Babalola S
        • Ibeawuchi C
        • et al.
        Role of religious leaders in promoting contraceptive use in Nigeria: evidence from the Nigerian Urban Reproductive Health Initiative.
        Glob Health Sci Pract. 2018; 6: 500