This study was carried out on the basis of the reasoned action theory, developed by Fishbein and Ajzen in 2011 [24]. This theory contains 4 main components, of which the attitude towards behavior, subjective norms, intention and behavior. However, in addition to acting as a determinant of intention, perceived and actual behavioral controls are presumed to have direct influence on behavior by reducing voluntary control over behavior. These components are influenced upstream by certain individual, socio-demographic and informational characteristics, Figure 1.

We hypothesized that adolescents’ and teachers’ knowledge, attitude and behavior regarding the uptake of the FP might be planned in a context governed by principles controlling these practices.

A qualitative study was organized from March to August 2018 in the commune of Lemba from Kinshasa and the sector of Gombe Matadi located in the province of Kongo Central. The data were collected by interviews and documents review. We organized six focus groups (FGs) of adolescents aged 15 - 19 and seven semi-structured interviews with teachers of the FLEC. The teaching program of the FLEC available in schools and the official training program drawn up by the MPSTE of the DRC were assessed in the light of international guidelines on sexuality education from UNESCO [15].

Teenagers were recruited from both the group of those in school and out-of-school. They were recruited from both male and female groups. Adolescents attending schools were identified from four high schools selected by convenience sampling, at the rate of two schools in Kinshasa and two schools in Gombe Matadi. In each high school, we collected the data from students in the 3rd, 4th and 5th grades selected by snowball. Out-of-school adolescents were identified by the snowball technique from an out-of-school adolescent of each gender, selected from the church, local associations or an informant. Six homogeneous FGs were organized at all, of which two FGs in Kongo Central (at the rate of one FG per gender) and four FGs in Kinshasa. Two out of four FGs planned in Kinshasa were organized with in school adolescent girls; one was organized with in school male adolescents and one targeted out-of-school male adolescents. Due to the fact that we did not reach the required minimum number

of participants, we were not able to organize the FG with out-of-school adolescent girls. Socio-demographic characteristics of teenagers interviewed for this study are shown in Table 1.

The teachers of the FLEC were recruited among those teaching in the 3rd, 4th, 5th and 6th grades. We interviewed at least one teacher per visited school. The main criterion for selecting teachers was their availability at the time of the survey and the fact that they were actually teaching the FLEC to adolescents aged 15 - 19 in the aforementioned classes. Table 2 describes the socio-demographic characteristics of the teachers interviewed through this study.

The six FGs were homogeneous, made up of 7 to 12 adolescents grouped according to their educational status, gender and place of residence. Using an interview guide, in school adolescents were interviewed after leaving school, for no more than two hours. The FG session with out-of-school adolescents took place for around two hours from a meeting room located near their home. The FLEC teachers were interviewed at the school place for a duration of 1:30, using another interview guide. All conversations were recorded on the dictaphone.

An interview guide for the FGs was developed based on the aforementioned reasoned action model. The main themes addressed in this guide focused on knowledge of FP methods, sources of information in SRH and FP; practices (behavior) of adolescents in SRH and FP; contraceptive attitudes and preferences (beliefs); the role of schools and family members in the comprehensive sexuality education of adolescents and the possible use of FP services and contraceptive methods by adolescents.

The teachers’ interview guide mainly included themes related to teachers’ knowledge in SRH and FP, the individual attitudes towards contraception; and the teacher’s attitude towards the demand of FP services by adolescents. The second group of themes was intended to understand the content of the FLEC taught at school and the process that led to the establishment of this training program. To carry out these analyzes, we relied on the guidelines for comprehensive sexuality education issued by UNESCO [15].

Qualitative data were analyzed following a deductive approach, using Atlas Ti software with reference to the theoretical framework of Fishbein and Ajzen. They were first analyzed by FG and semi-structured interviews and by theme in order to identify the thread of ideas. The data were then analyzed grouped for all FGs and all semi-structured interviews. From each theme (knowledge, attitude and practice on FP), we selected open and axial codes that helped to process with the analysis. We split the data, followed by their analysis for differences and similarities. We analyzed respondents’ answers to identify similarities through keyword research; similar concepts were labeled with the same name. Each concept was then defined in terms of a set of discrete properties and dimensions to add clarity and understanding. Open codes consisted of highlighting what had been reported multiple times, as well as aspects of behavior taken for granted. With axial codes, it was possible to create new sub-topics by grouping together sentences and words. By using axial coding, we were able to indicate how connections are made between categories and subcategories thus created. The second part of the analytical process dealt with the differentiation between open and axial codes. The dissimilarities were analyzed to understand the essence conveyed through the key words of the interviewees. The themes appearing in the results section are from open and axial codes.

To understand the organization of the teaching program of FLEC taught at school and the process that led to the establishment of this training program, we analyzed the course preparation registers of targeted teachers; and then, we discussed with teachers and students concerning the content of the course.

Before their dissemination, the results of this study were discussed with students and teachers from a high school. This procedure made it possible to validate the results by further improving the presentation.

The results cover three themes that could explain the barriers to initiatives aiming to improve contraceptive use among adolescents.

Knowledge and sources of information on contraception

No significant difference was noted between in-school and out-of-school adolescents regarding their knowledge and sources of information on contraception. Almost all adolescents knew the risks of unprotected sex. They allude to the risk of unwanted pregnancy and sexually transmitted infections (STIs) such as HIV-AIDS. As for ways to prevent the risk of unwanted pregnancies, adolescents cited periodic abstinence, pills and male condoms. However, no sexually active adolescents, both in and out of school, had a negative opinion about the use of modern contraceptive methods. A teenager said this: “We can use condoms and other drugs advertised on television to protect against the occurrence of unwanted pregnancies but I believe that all this is not recommended for both boys and girls, condoms can lead to prostate disease, you just need to abstain’’ (TM, 16 years old, FG 5).

A significant portion of interviewees believed that it was better to abstain from sex in adolescence and to wait until adulthood or marriage to practice sex. One teenage girl confided in saying this: “A minor is still irresponsible, he does not know how to protect himself or how to take charge of himself in the event of a problem; care should be taken to refrain from sexual intercourse” (JK, participant 2, FG 2). However, sexually active adolescents favored the use of natural than modern contraceptive methods to prevent unintended pregnancies. Apart from the use of condoms, they believed that modern contraceptive methods are not free from risks to their health. To do this, they preferred to use the traditional methods they had heard about. A teenage girl said the following: “The girl must know how to calculate her ovulation periods, this protects better than the drugs and condoms which can make the woman sterile” (MN, 18, FG 1).

Sexual abstinence seems to be imposed on some adolescent girls by the family and the society. This idea was indirectly reflected by the superfluous reasons put forward when adolescents were asked to justify their opinion towards abstinence. The age of majority was falsely considered by some of them as a protective factor against the risks of unprotected sex. Adolescents linked age to responsibility for actions and their health consequences. A school-going teenager confided in these terms: “For me, young people are not prohibited from having sex, but we are asked to wait until the age of 18 to do so. There is little risk when a teenager has sex from the age of 18. Girls who have sex at 15 - 16 years old this is not good, you just have to wait because before that age when the girl gets pregnant, the boy author of the pregnancy is irresponsible; he will push to have an abortion and that poses problems’’ (NA, 16 years old, FG 3).

According to the interviews with the FLEC’s teachers, contraceptive methods, even the most common ones, were little known among many of them. In their majority, they cited the periodic abstinence and condoms as the most known contraceptive methods. However, self-observation methods; interrupted coitus; intra-uterine device (IUD); spermicides, pills and implants were cited by one in three interviewees.

The sources of information on SRH differed depending on whether it was boys or girls. Most male adolescents cited the school, friends and the media (internet) as the main sources of SRH information; adolescent girls added their mothers, older sisters and friends among their sources of information. Parents, especially fathers, were not considered as a reliable source of information on SRH. The majority of teens did not confide in their fathers when they needed information about SRH. Some encountered a negative attitude of their father as reported by a teenager: “A neighbor got pregnant; when I asked our daddy how can a young girl protect herself from unwanted pregnancies, daddy said to me: why do you want to know, to go to practice?’’ (BK, 4th scientist). For teachers, the main sources of information on SRH for adolescents are phones, the internet, school, diffuse education, media and movies. Teachers were aware that the FLEC does not address certain concerns raised in class by teenagers as shown through below statement: “School is not enough today to inform adolescents about FP, it is especially the street, street education that influences the behavior of adolescents” (Teacher 7, 20 years of seniority). Although they teach this course, they are aware that the current content of the FLEC program has little influence on the SRH knowledge and behavior of adolescents. Another teacher declared: “The FLEC doesn’t influence teens much today; rather, it is diffuse education that has more influence on adolescents; the school gives the FLEC but the children are more informed by the media, the colleagues, and the other people especially concerning the problems not addressed during the course; at school we are limited, but in the city it is more” (Teacher 4, 2 years of experience). The school was the preferred source of information on SRH for adolescents, followed by parents; caregivers were preferred especially by out-of-school adolescents. For 4th and 5th year high school students, the FLEC does not address certain SRH concerns because some teachers refuse to answer these concerns.

Attitudes and practices towards contraception

Adolescents and teachers were not in favor of the use of contraceptive methods, apart from natural (traditional) methods. They had an unfavorable attitude towards the uptake of modern contraceptives. A teacher said the following: “I don’t think a 15, 16, 17-year-old teenager can use a FP method, they sometimes use condoms to avoid giving birth” (Teacher N˚5, Kinshasa). They do not intend to use modern contraceptive methods in the future or to advise them to family members: “I personally use the natural method by calculating the date of my wife’s menstruation, I do not use other methods such as condoms. At home, I insist on abstinence, I refuse to allow children to use condoms, otherwise they will have a taste for sex; me their daddy if I live to this age it is because I behaved well in my life, I never had to have sex anyhow, since I studied at university I had the decision to have only one woman in my life’’ (Teacher N˚7, Kinshasa). The use of contraceptive methods was linked to knowledge and attitudes towards these methods. When asked about what contraceptive methods he knew; a teacher said the following:

“I know abstinence; I have no idea about the leftover methods; I am single and I abstain from sex; I personally have never used contraceptive methods; these methods are for the married, those who live as a couple” (Teacher N˚5, Kinshasa).

The MPSTE is responsible for developing the curriculum of the FLEC in high schools. However, in visited schools, no official curriculum for the FLEC was available. Teachers developed a local training program by taking into account their own knowledge. During discussions with teachers and pupils, various programs of the FLEC were found, depending on the type of school and the class. The FLEC was taught from the 1^st to the 6^th grade in the majority of high schools. In a few schools, the FLEC was taught from the 3^rd to 6^th year of high schools. We tried to bring together different themes that were addressed in each class of high school by grouping together the data obtained from the review of teaching programs and interviews with students. Table 3 summarizes local programs of FLEC developed by teachers in visited schools.

The training programs varied according to the schools and according to the basic training of the teacher. According to the majority of adolescents, the training revolved around the following points: abortions, virginity, chastity, HIV AIDS, risk of early childbirth, responsible sex, marriage. These are the superficial concepts of preventing unintended pregnancies. Table 4 analyzes the content of the training program in SRH applied in schools in the light of the guidelines given by UNESCO.

It emerges from this analysis that certain important topics are not generally

addressed in class throughout the training cycle of students in the field of comprehensive sexuality education. In the topic of pregnancy and prevention of pregnancy, students are taught to abstain from sex by observing chastity. Contraception was not specifically discussed in class, for example, with regards to its advantages and benefits for the health of women, the family and the community. In addition, this course could be an opportunity to improve adolescent knowledge of natural (traditional) contraceptive methods with a view to improving their correct use. However, some teachers find it dangerous to teach FP concepts to students according to their statements: “Teaching FP is a serious problem, there are students who have already had sex; others have not yet reached this stage, they must be taught to avoid sex, physical abstinence, because even if we use condoms it can rupture and pregnancy can intervene. Even the use of drugs, I don’t agree with that; me when I entered college to study, I was told that all girls are sick, even if we use a condom it can break and you will get sick’’ (Teacher 6, 2 years of experience).

The data collection also helped to find that teaching the FLEC did not benefit from the follow-up by the inspectors of the education service as this is the case of other courses. All interviewed teachers declared that for years, they had never received visits from school inspectors; but for other courses like biology, microbiology, science, the inspectors supervise the teacher because they have the schedule. A teacher said: “I have not yet received a visit from the school inspectors, but for the other courses I teach in this school they supervise. In the FLEC sometimes they look outside glancing but coming into the room to attend as an official visit, no” (Teacher 6).