Confidentiality Breaches and Shame Keep Rural Sierra Leone’s Teen Girls From Contraception

Adolescent girls in rural Sierra Leone are being shut out of contraception and other sexual and reproductive health services not primarily by their own reluctance, but by four interlocking mechanisms that operate at the level of family, clinic and community, according to a qualitative participatory study published in the journal Contraception and Reproductive Medicine. The research, conducted between February and July 2024 across three rural districts, identifies internalised shame reinforced by community surveillance, confidentiality breaches by health providers, compounding structural barriers such as contraceptive stockouts and judgmental provider attitudes, and the effective loss of schooling after pregnancy as the forces that together suppress help-seeking among teenage girls.

The urgency of the problem is underlined by Sierra Leone’s demographic profile. The country has one of the highest adolescent birth rates globally, at approximately 101 births per 1000 girls aged 15 to 19 years. Although stigma, provider attitudes, confidentiality concerns, supply shortages and distance are already established barriers to adolescent sexual and reproductive health service access across sub-Saharan Africa, and Sierra Leone’s high adolescent birth rate and fragile rural health infrastructure are well documented, the authors note that qualitative evidence specific to rural Sierra Leone, particularly evidence generated through participatory methods involving adolescent girls themselves, has remained limited.

The study set out to explore how adolescent girls experience sexual and reproductive health service access in rural Sierra Leone, with specific attention to the social and institutional mechanisms that suppress help-seeking. To do so, the researchers employed a qualitative participatory design in Koinadugu, Moyamba and Pujehun districts. Eighty-seven participants were engaged through in-depth interviews, focus group discussions, guided storytelling and service-access journey mapping. The primary analytic group comprised 32 adolescent girls aged 15 to 19 years. These 32 girls were the primary analytic focus, while the remaining 55 participants, including young mothers, parents and guardians, teachers, community health workers, nurses and midwives, youth leaders, and community and religious leaders, provided complementary perspectives that enabled triangulation of the findings.

The methodological division of labour was deliberate. In-depth interviews were conducted with adolescent girls and young mothers, focus group discussions were held with the community stakeholder groups, and guided storytelling and journey mapping were carried out with the adolescent girls. This combination of participatory tools allowed the researchers to capture not only what girls said about access barriers in conversation, but also how they physically and socially navigate the route to care.

Four themes emerged from the analysis. The first concerns internalised shame and community surveillance as co-constitutive barriers to help-seeking. In other words, the shame that girls absorb about adolescent sexuality and the watchfulness of their communities do not act separately; each reinforces the other. A girl who anticipates being seen approaching a clinic for contraception internalises the judgement she expects, and the visible presence of neighbours and acquaintances around health facilities confirms that expectation. The result is a self-reinforcing loop in which the social cost of seeking care is paid before any service is even reached.

The second theme identifies provider disclosure as a systemic confidentiality failure with community-wide deterrent effects. This finding goes beyond the familiar observation that adolescents fear their privacy will not be respected. According to the study’s key messages, a single provider disclosure travels through kinship and peer networks, so that one breach of confidentiality deters many girls from seeking care. Confidentiality, the authors argue, should therefore be measured not only as an individual patient right but as a community-level determinant of service use. When a nurse or midwife reveals that a teenage patient sought contraception, the consequences ripple outward through families and friendship groups, chilling demand across an entire peer network rather than affecting only the girl who was betrayed.

The third theme documents compounding structural barriers: judgmental provider attitudes, contraceptive stockouts, provider-generated misinformation and geographic inaccessibility. A particularly striking element of this theme is the study’s documentation that contraceptive misinformation is actively generated by providers themselves, not only by peer networks. Girls who summon the courage to attend a facility may therefore encounter inaccurate claims about contraception from the very health workers who should be reliable sources of evidence-based information, layered on top of unreliable supply and the practical difficulty of reaching distant clinics. Each barrier compounds the others, so that overcoming one still leaves a girl facing the rest.

The fourth theme concerns education. The study found that pregnancy acts as an effective terminator of educational trajectories despite formal policy protections. Sierra Leone has a policy that allows pregnant girls to return to school, but the research indicates that in practice, pregnancy ends girls’ schooling. The authors recommend enforcement of this re-entry policy as one of the concrete actions needed, alongside the other measures their findings support.

The participatory methods yielded distinctive insights that conventional interview-based approaches alone would not have surfaced. Journey mapping data distinctively illustrated how girls spatially navigate exposure risk at health facilities. Spatially, girls mapped the health facility as a place of exposure, where market traders, neighbours and religious figures positioned near facility entrances can see them arriving. This spatial dimension of access, the authors note, demonstrates the value of participatory tools such as journey mapping for revealing aspects of the service-access experience that interview-based methods alone do not capture. The mapping exercise reframes the clinic visit not as a single confidential encounter but as a publicly observable journey whose every stage carries social risk.

Alongside these barriers, the study records a constructive finding: girls articulate clear reproductive aspirations that are blocked by systemic rather than motivational barriers. The problem, in other words, is not that rural adolescent girls lack the desire to plan their reproductive lives, but that the systems around them make acting on those plans costly and risky.

The findings carry direct implications for policy and practice in Sierra Leone and comparable settings. The authors state that the evidence provides actionable material for the Sierra Leone Ministry of Health to codify mandatory adolescent confidentiality protocols, incorporate adolescent-specific commodity forecasting into supply planning, and enforce the pregnant girls’ school re-entry policy, with relevance to comparable rural, low-resource settings implementing adolescent-friendly health service standards. On the provider side, they indicate that investment should move beyond training towards enforceable service defaults, supportive supervision, client feedback and recognition of non-judgmental care, so that respectful treatment becomes a structural feature of services rather than a matter of individual worker disposition.

Supply-side and community-level recommendations follow the same logic of lowering the cost of access. The authors highlight reliable contraceptive supply, self-care and community-based delivery channels that reduce the exposure cost of obtaining contraception, comprehensive sexual and reproductive health and rights literacy paired with peer advocacy, and community engagement. Delivery models that allow girls to obtain contraception outside the visible clinic setting, combined with peer networks that normalise use, offer a route to access that does not require girls to absorb the cost of community exposure.

For the research community, the study offers two methodological lessons. First, confidentiality should be conceptualised and measured not only as an individual patient right but as a community-level determinant of service use, since a single breach can suppress demand across networks of girls who never experienced the breach themselves. Second, participatory tools such as journey mapping can surface spatial dimensions of access, such as the placement of traders and religious figures near facility entrances, that interviews alone do not reveal. The study is published as open access research, with the accepted manuscript shared early to provide faster access; it is citable and carries a permanent DOI, and this version is subject to further edits before the final Version of Record replaces it.

Taken together, the four themes sketch a system in which adolescent girls in rural Sierra Leone are excluded from contraceptive and other sexual and reproductive health services by mechanisms that operate simultaneously within the self, the clinic and the community. The study’s contribution is to show how these mechanisms interlock, and to identify where enforceable changes to confidentiality protocols, supply chains, provider accountability and school re-entry policy could begin to dismantle them.

Subject of Research: Barriers to adolescent girls' access to contraception and sexual and reproductive health services in rural Sierra Leone

Article Title: A qualitative participatory study on adolescent girls’ access to contraception and other sexual and reproductive health services in rural Sierra Leone

Article References: Osborne, A., Yillah, R. M., Olorunsaiye, C. Z., Kamara, I. F., Bangura, C., Seidu, A.-A., & Ahinkorah, B. O. (2026). A qualitative participatory study on adolescent girls’ access to contraception and other sexual and reproductive health services in rural Sierra Leone. Contraception and Reproductive Medicine. https://doi.org/10.1186/s40834-026-00480-w

Image Credits: AI Generated

DOI: 10.1186/s40834-026-00480-w

Keywords: adolescent health, contraception, Sierra Leone, sexual and reproductive health, qualitative research, participatory methods, confidentiality, health services, journey mapping, school re-entry, sub-Saharan Africa, thematic analysis