Multiple Levels of Social Influence On Adolescent Sexual and Reproductive Health Decision-Making and Behaviors in Ghana
Multiple Levels of Social Influence On Adolescent Sexual and Reproductive Health Decision-Making and Behaviors in Ghana
Multiple Levels of Social Influence On Adolescent Sexual and Reproductive Health Decision-Making and Behaviors in Ghana
Sneha Challa MPH, Abubakar Manu PhD, Emmanuel Morhe MD, FWACS,
MPH, Vanessa K. Dalton MD, MPH, Dana Loll MHS, Jessica Dozier, Melissa
K. Zochowski MBA, Andrew Boakye MPH, Richard Adanu MD & Kelli
Stidham Hall PhD, MS
To cite this article: Sneha Challa MPH, Abubakar Manu PhD, Emmanuel Morhe MD, FWACS,
MPH, Vanessa K. Dalton MD, MPH, Dana Loll MHS, Jessica Dozier, Melissa K. Zochowski MBA,
Andrew Boakye MPH, Richard Adanu MD & Kelli Stidham Hall PhD, MS (2017): Multiple Levels of
Social Influence on Adolescent Sexual and Reproductive Health Decision-Making and Behaviors in
Ghana, Women & Health, DOI: 10.1080/03630242.2017.1306607
Download by: [The UC San Diego Library] Date: 16 March 2017, At: 05:49
Multiple Levels of Social Influence on Adolescent
Sexual and Reproductive Health Decision-Making
and Behaviors in Ghana
Sneha Challa, MPH
Department of Health Behavior and Health Education, University of Michigan School of Public
Health, Saratoga, California, USA
Jessica Dozier
Richard Adanu MD
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Abstract:
Little is known about the multi-level social determinants of adolescent sexual and reproductive
health (SRH) that shape the use of family planning (FP) among young women in Africa. We
conducted in-depth, semi-structured, qualitative interviews with 63 women aged 15-24 years in
Accra and Kumasi, Ghana. We used purposive, stratified sampling to recruit women from
community-based sites. Interviews were conducted in English or local languages, recorded, and
transcribed verbatim. Grounded theory-guided thematic analysis identified salient themes. Three
primary levels of influence emerged as shaping young women’s SRH experiences, decision-
making, and behaviors. Interpersonal influences (peers, partners, and parents) were both
supportive and unsupportive influences on sexual debut, contraceptive (non)use, and pregnancy
of adolescent sexual activity and its consequences (pregnancy, childbearing, abortion). Macro-
social influences involved religion and abstinence and teachings about premarital sex, lack of
comprehensive sex education, and limited access to confidential, quality SRH care. The
willingness and ability of young women in our study to use FP methods and services were
affected, often negatively, by factors operating within and across each level. These findings have
implications for research, programs, and policies to address social determinants of adolescent
SRH.
Keywords: sexual health; reproductive health; family planning; social determinants of health;
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Received 31 Aug 2016
Department of Health Behavior and Health Education, University of Michigan School of Public
Health, 12300 Fredericksburg Ct. Saratoga, CA 95070, USA.
schalla90@gmail.com
Background
Adolescence is a time of intense biological, psychological, and social development, during which
(UNICEF 2002). Factors at the individual-, interpersonal-, community- and systems-levels may
health and wellbeing across the life course (Adebayo et al. 2015; Ballard and Syme 2015;
Ritterman Weintraub et al. 2015; Santelli et al. 2013; UNFPA 2007). In fact, life course theory
suggests that social patterns in adolescence significantly affect actions, behavior, and
development (Elder 1998). For adolescent sexual and reproductive health (SRH), specific social
influences have been of interest in global research on adverse outcomes, such as unintended
pregnancy and sexually transmitted infections (STIs) (Garwood et al, 2015; Hall et al. 2015;
Nagarkar and Mhaskar 2015). For example, studies in the U.S., Europe, and Africa have reported
similar findings regarding isolated factors, such as educational attainment, poverty level, and
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violence for their independent relations to early childbearing and HIV/AIDS acquisition
(Cordova Pozo et al. 2015; Nyarko 2015; Sprague 2015). Yet, a broader conceptualization of the
multiple, diverse, and potentially interactive, social determinants of adolescent SRH has not been
In Sub-Saharan Africa, where issues of economic instability, violence, and political, legal, and
economic barriers to comprehensive, quality health care and education exist (Lince-Deroche et
al. 2015; Otwombe et al. 2015), adolescent SRH may be particularly vulnerable to outside
influences. Countries such as Ghana experience unmet needs for family planning (FP) resulting
in high rates of adolescent childbearing, abortion, and maternal mortality, despite the
settings (Abdul-Rahman et al. 2011; Adjei et al. 2015; Apanga and Adam 2015). It is possible
that restrictive sociocultural norms and attitudes toward adolescent SRH act in tandem with
structural factors, as well as interpersonal ones, to influence adolescents’ willingness and ability
to engage SRH care; however, this has not been comprehensively studied (Levandowski et al.
2012; McGuire and Stephenson 2015). Gender norms that emphasize motherhood, religious
norms regarding the immorality of sex outside of marriage, or cultural norms that devalue
adolescence as a life stage, for instance, may shape systems-level approaches to adolescent SRH
care and education (Harrington et al. 2015; Jesmin and Cready 2015; Macpherson et al. 2014).
These complex, potentially interactive, and even conflicting social factors are likely to affect
young women’s abilities to make informed decisions about sex, contraception, and childbearing,
ultimately precluding healthy SRH behaviors and outcomes (Hoopes et al. 2015; Michaud et al.
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2015). Yet, studies to date have largely focused on individual-level, specific proximal
interrelated set of social factors that influence SRH during adolescence (Dessie, Berhane, and
Worku 2015; Marrone et al. 2014; Sileo et al. 2015; Wang et al. 2014). Research is thus needed
to address comprehensively and formally the social environment of adolescent SRH for young
As part of a larger mixed methods study focused on the role of stigma in adolescent access to and
use of FP, the current study qualitatively explored the broader social ecological context of
adolescent SRH in Ghana and the various social influences on young women’s SRH decision-
Methods
Study Population
Using a community-based cluster sampling technique, we selected school- and clinic-based sites
through the Ghana Educational Service (GES) and the Ghana Health Service (GHS) in Accra and
Kumasi, Ghana. Five public sector senior high schools and five GHS facilities were selected to
maximize diversity in school type (female only, co-education, public) and clinic type (family
planning, adolescent, antenatal, postnatal, abortion, and child welfare) and the populations they
The overall number of schools and clinics is not available from the Ghanaian Educational System
and the Ghana Health Service. Thus, we are unable to report what proportion the selected schools
and clinics were of all schools and clinics in the studied areas. Purposive sampling enhanced
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recruitment of a heterogeneous sample of women and enhanced the likelihood that sufficient
numbers of women were enrolled from the recruitment sites in both cities to achieve data
saturation. Only public sector schools were sampled as they served the largest populations of
young women in each city and were diverse in distributions by ethnicity, socioeconomic status,
Dengan menggunakan teknik pengambilan sampel klaster berbasis masyarakat, kami memilih situs berbasis
sekolah dan klinik melalui Ghana Educational Service (GES) dan Ghana Health Service (GHS) di Accra dan
Kumasi, Ghana. Lima sekolah menengah atas sektor publik dan lima fasilitas GHS dipilih untuk memaksimalkan
keragaman jenis sekolah (khusus perempuan, pendidikan bersama, umum) dan jenis klinik (keluarga berencana,
remaja, antenatal, nifas, aborsi, dan kesejahteraan anak) dan populasi mereka melayani (yaitu, berbagai
karakteristik latar belakang sosio-demografis dan reproduksi perempuan). Jumlah keseluruhan sekolah dan klinik
tidak tersedia dari Sistem Pendidikan Ghana dan Layanan Kesehatan Ghana. Dengan demikian, kami tidak dapat
melaporkan berapa proporsi sekolah dan klinik yang dipilih dari semua sekolah dan klinik di wilayah studi.
Pengambilan sampel secara purposif meningkatkan perekrutan sampel perempuan heterogen dan meningkatkan
kemungkinan bahwa jumlah perempuan yang cukup terdaftar dari lokasi rekrutmen di kedua kota untuk
mencapai kejenuhan data. Hanya sekolah sektor publik yang dijadikan sampel karena mereka melayani populasi
wanita muda terbesar di setiap kota dan memiliki distribusi yang beragam menurut etnis, status sosial ekonomi,
Eligible women were aged 15-24 years and spoke English or one of two local languages (Twi or
Ga). Research Assistants (RAs) or contact nurses at the sites initially screened potential
participants, and those deemed eligible were provided additional information about the study and
invited to participate. Recruitment and enrollment concluded when data saturation was reached.
In total, 72 young women were approached. Four were excluded due to the language criteria, and
another five declined to participate. The final sample included 63 women. Participants were
offered a small token (e.g. $2 cedis telephone cards) as compensation for their time.
Wanita yang memenuhi syarat berusia 15-24 tahun dan berbicara bahasa Inggris atau salah satu
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dari dua bahasa lokal (Twi atau Ga). Asisten Peneliti (RA) atau perawat kontak di lokasi awalnya
menyaring calon peserta, dan mereka yang dianggap memenuhi syarat diberi informasi tambahan
tentang penelitian dan diundang untuk berpartisipasi. Perekrutan dan pendaftaran selesai ketika
kejenuhan data tercapai. Secara total, 72 wanita muda telah didekati. Empat dikeluarkan karena
kriteria bahasa, dan lima lainnya menolak untuk berpartisipasi. Sampel akhir termasuk 63 wanita.
Peserta ditawari token kecil (misalnya kartu telepon cedi $ 2) sebagai kompensasi atas waktu
mereka.
Given the sensitive nature of this work, researcher team members obtained parental consent
waivers from all Ghanaian Institutional Review Boards (IRBs) to ensure confidentiality for the
participants. Verbal consent was obtained from all participants after they were read information
about the study and their rights. Additionally, all institutions provided participation agreements.
Approval of the study protocol was obtained from The University of Ghana, the University of
Mengingat sifat sensitif dari pekerjaan ini, anggota tim peneliti memperoleh pengabaian izin orang
tua dari semua Dewan Peninjau Institusional (IRB) Ghana untuk memastikan kerahasiaan bagi
para peserta. Persetujuan lisan diperoleh dari semua peserta setelah mereka membaca informasi
tentang penelitian dan hak-hak mereka. Selain itu, semua institusi memberikan perjanjian
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Data collection
Trained RAs, who were bachelors or masters degree candidates, prepared and conducted
semi-structured, in-depth, individual interviews that ranged from 30-90 minutes in length. RAs
underwent extensive interviewer training with our Principal Investigators (PIs) to ensure fidelity
and internal consistency of interviews. With consent from participants, each interview was
recorded digitally and then transcribed verbatim. Interviews took place in private offices and
used semi-structured guides, which were organized by topic, in order of increasing sensitivity, to
enhance rapport with participants and data validity. Interview guides were informed by a
literature review on the factors associated with adolescent SRH (including social causes and
consequences) and on stigma and health (a focus of our larger study). Interview guides with open-
ended questions were designed to elicit information regarding reproductive and contraceptive
histories, knowledge of/attitudes toward SRH, and perceived community norms with respect to
adolescent sexual activity, pregnancy, abortion, childbearing, contraception, STIs, and use of FP
services.
For participants who were sexually active, pregnant, or previously pregnant, the interview guides
experiences; 3) changes in life goals (e.g., childbearing, marriage, employment, education); and
4) perceived barriers to and experiences with use of FP, antenatal, and/or postpartum services.
community norms and the experiences of women in their communities (e.g., peers, social
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networks). RAs also collected routine sociodemographic, health and reproductive history
information.
Data Analysis
The thematic analysis was guided by principles of grounded theory and narrative inquiry, using
both inductive and deductive approaches. Thus, it was informed by preexisting themes from the
literature, as well as codes that arose from the data and which reflected participants’ language
and discourse. Initially, multiple study team members independently reviewed the transcripts.
Weekly meetings enabled team members to review transcripts together, discuss data, make
coding decisions, refine coding definitions, resolve any discrepancies in coding strategy, discuss
reflexivity and bias, and modify our coding scheme as negative cases (young women whose
experiences did not fit the pattern or were an exception to the findings of others being studied)
emerged, all of which helped to reduce bias and selectivity. Regular conversations between U.S.
and Ghanaian team members provided opportunities to address reflexivity, share preconceptions,
and consider competing conclusions (Glaser and Strauss, 1967). Using an iterative process, we
created and refined a formal codebook. Two U.S.-based team members, different from the RAs
that conducted the interviews, then coded all transcripts independently and met to reconcile
discrepancies in coding. We used Dedoose software to manage and analyze the data.
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Results
The final sample included 63 participants (Table 1) who shared information about factors
that influenced their SRH experiences, including sexual activity, contraception, STIs, pregnancy,
abortion, childbearing, and FP service use, of young women in their community. Factors
described were largely social influences that occupied and cut across different levels of their
environments. These findings, which we have organized by a social ecological framework, are
presented below.
Sampel akhir terdiri dari 63 peserta (Tabel 1) yang berbagi informasi tentang faktor-faktor
yang mempengaruhi pengalaman SRH mereka, termasuk aktivitas seksual, kontrasepsi, IMS,
kehamilan, aborsi, melahirkan, dan penggunaan layanan KB, dari remaja putri di komunitas
mereka. Faktor-faktor yang dijelaskan sebagian besar adalah pengaruh sosial yang menempati dan
melintasi berbagai tingkat lingkungan mereka. Temuan ini, yang kami susun berdasarkan
Interpersonal Level
Interpersonal influences on young women’s SRH decision-making and behaviors were described
by most participants through stories of interactions with peers, partners, and parents. Female
peers were frequently trusted as confidantes, consultants and the first source of information on
sex, reproduction, contraception and FP/STI services, guidance on pregnancy resolution and
abortion decisions, or assistance with childbearing responsibilities. Peers also shared financial
and physical resources and emotional support. However, peer exchanges were not always
supportive or positive, and by disclosing SRH activity or outcomes (e.g., pregnancy), young
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women were vulnerable to criticism about their decisions or to unwelcome advice. A 15-year-old
Pengaruh interpersonal pada pengambilan keputusan dan perilaku SRH wanita muda dijelaskan
oleh sebagian besar peserta melalui cerita interaksi dengan teman sebaya, mitra, dan orang tua.
Teman sebaya perempuan sering dipercaya sebagai orang kepercayaan, konsultan dan sumber
informasi pertama tentang seks, reproduksi, kontrasepsi dan layanan KB / IMS, panduan resolusi
kehamilan dan keputusan aborsi, atau bantuan dalam tanggung jawab melahirkan anak. Teman
sebaya juga berbagi sumber daya keuangan dan fisik serta dukungan emosional. Namun,
pertukaran teman sebaya tidak selalu mendukung atau positif, dan dengan mengungkapkan
aktivitas atau hasil SRH (misalnya, kehamilan), wanita muda rentan terhadap kritik tentang
keputusan mereka atau saran yang tidak diinginkan. Seorang siswa berusia 15 tahun di Accra
menggambarkan ini:
When she has a close friend who also engages in (sex), and she tells the friend she wants to use
family planning, the friend will be like, ‘Why does she want to? She should just do it and not use
any family planning.’ Since she doesn’t want her friend to be mad at her, she will go in for it
Ketika dia memiliki teman dekat yang juga terlibat dalam (seks), dan dia memberi tahu temannya
bahwa dia ingin menggunakan keluarga berencana, teman itu akan seperti, 'Mengapa dia mau? Dia
harus melakukannya dan tidak menggunakan keluarga berencana. 'Karena dia tidak ingin
temannya marah padanya, dia akan melakukannya (seks) tanpa menggunakan metode keluarga
berencana.
Peers were also described as a source of pressure, especially to initiate sex. A 17-year-old
student from Kumasi commented: “I think some don’t listen (to religious leaders) due to peer
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pressure because we listen to our friends more than what pastors always preach.”
Teman sebaya juga digambarkan sebagai sumber tekanan, terutama untuk memulai seks. Seorang
siswa berusia 17 tahun dari Kumasi berkomentar: "Saya pikir beberapa tidak mendengarkan
(pemimpin agama) karena tekanan teman sebaya karena kita mendengarkan teman kita lebih dari
Perceived parental support was also a significant determinant of most participants’ SRH decision-
making and behavior. Mothers were a primary source of financial and logistical support during
pregnancy, childbearing and child rearing for some women. Mothers were also reported to serve
as trustworthy sources of SRH information and guidance for some participants. However,
keeping sex, pregnancy, or abortion a secret was a strategy frequently employed to avoid being
disowned, abused (verbally or physically), or ejected from the home by family. A 20-year-old
Dukungan orang tua yang dirasakan juga merupakan penentu yang signifikan dari pengambilan
keputusan dan perilaku SRH sebagian besar peserta. Para ibu merupakan sumber utama dukungan
finansial dan logistik selama kehamilan, melahirkan dan mengasuh anak bagi beberapa wanita.
Para ibu juga dilaporkan berfungsi sebagai sumber informasi SRH dan bimbingan yang dapat
dipercaya bagi beberapa peserta. Namun, merahasiakan seks, kehamilan, atau aborsi adalah
strategi yang sering digunakan untuk menghindari penolakan, pelecehan (verbal atau fisik), atau
dikeluarkan dari rumah oleh keluarga. Seorang pasien klinik antenatal hamil berusia 20 tahun dari
Accra mengatakan:
Most parents, most families, when their ward gets pregnant, they sack her from home. They
don’t care what she eats, where she sleeps. They don’t care because she got herself into it, so she
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Kebanyakan orang tua, kebanyakan keluarga, ketika lingkungan mereka hamil, mereka
memecatnya dari rumah. Mereka tidak peduli apa yang dia makan, di mana dia tidur. Mereka tidak
peduli karena dia terlibat, jadi dia bisa menjaga dirinya sendiri.
On the other hand, for some young women in households facing financial hardship, parents
promoted sex as a means of providing family income. A 17-year-old Kumasi student stated,
“Sometimes parents encourage their wards to (have sex) for money when there is financial
Di sisi lain, bagi sebagian remaja putri dalam rumah tangga yang menghadapi kesulitan keuangan, orang tua mempromosikan seks
sebagai cara untuk memberikan penghasilan keluarga. Seorang siswa Kumasi berusia 17 tahun menyatakan, "Kadang-kadang orang
tua mendorong lingkungan mereka untuk (berhubungan seks) demi uang ketika ada kesulitan keuangan di rumah dan juga tekanan
dari teman sebaya."
For most participants, intimate partners were described as a predominant interpersonal influence.
Sexual coercion, violence, and forced alcohol and substance use from a partner or casual
acquaintance were the most consistently cited determinants of initiating sexual activity and/or
engaging in ongoing unwanted and unprotected sex. A 15-year-old student from Kumasi
Bagi sebagian besar peserta, pasangan intim digambarkan sebagai pengaruh interpersonal yang
dominan. Pemaksaan seksual, kekerasan, dan penggunaan alkohol dan obat-obatan secara paksa
dari pasangan atau kenalan biasa adalah penentu yang paling sering dikutip untuk memulai
aktivitas seksual dan / atau terlibat dalam hubungan seks yang tidak diinginkan dan tanpa kondom.
Seorang siswa berusia 15 tahun dari Kumasi menggambarkan pengalaman seorang teman:
She was given alcohol after a party, then the guy bought condoms and told her he wanted to have
sex with her. She refused because she is not ready, but later the guy got angry and because she
Dia diberi alkohol setelah pesta, kemudian pria itu membeli kondom dan mengatakan kepadanya
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bahwa dia ingin berhubungan seks dengannya. Dia menolak karena dia tidak siap, tetapi kemudian
pria itu marah dan karena dia mencintai pria itu, dia menyerah.
Partner coercion was also a tactic used against some participants to perpetuate nonuse, misuse, or
discontinuation of contraceptive methods. Although not explicitly cited (or perhaps even
recognized) by participants, some told stories that hinted at imbalances in power dynamics and
intimate relationships and FP experiences. While pregnancy intentions were not always directly
described, discordant intentions between young women and their partners appeared to be a
frequent theme. A 17-year-old pregnant antenatal clinic patient said of her own experience:
Pemaksaan pasangan juga merupakan taktik yang digunakan terhadap beberapa peserta untuk
Meskipun tidak dikutip secara eksplisit (atau mungkin bahkan diakui) oleh peserta, beberapa
norma gender prokreasi seputar keibuan dan melahirkan sebagai dasar hubungan intim perempuan
dan pengalaman KB. Meskipun niat hamil tidak selalu dijelaskan secara langsung, ketidaksesuaian
antara wanita muda dan pasangannya tampaknya sering menjadi tema. Seorang pasien klinik
I didn’t stop it (using a condom). My boyfriend decided to stop using it. When he did that, I told
him that I was also going to stop seeing him, and so he came to reveal himself to my parents. He
said that he wanted me to get pregnant and give birth for him…that he has already told his
parents about it. He also said that after I give birth, he will help me get a job.
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Saya tidak menghentikannya (menggunakan kondom). Pacar saya memutuskan untuk berhenti menggunakannya. Ketika dia
melakukan itu, saya mengatakan kepadanya bahwa saya juga akan berhenti bertemu dengannya, jadi dia datang untuk
mengungkapkan dirinya kepada orang tua saya. Dia mengatakan bahwa dia ingin saya hamil dan melahirkan untuknya… bahwa dia
telah memberi tahu orang tuanya tentang hal itu. Dia juga mengatakan bahwa setelah saya melahirkan, dia akan membantu saya
mendapatkan pekerjaan.
Partners also influenced pregnancy decision-making and resolution for many participants, which
was described as a complex process in which young women balanced her and her partner’s
feelings with social norms around premarital sex, childbearing, and abortion. A 21-year-old
woman from an Accra clinic who had previously been pregnant described this:
Pasangan juga memengaruhi pengambilan keputusan dan resolusi kehamilan bagi banyak peserta,
yang digambarkan sebagai proses kompleks di mana perempuan muda menyeimbangkan perasaan
dirinya dan pasangannya dengan norma sosial seputar seks pranikah, melahirkan, dan aborsi.
Seorang wanita berusia 21 tahun dari klinik Accra yang pernah hamil menjelaskan hal ini:
When I realized that I was pregnant, I told the man I was with. He told me to give birth.
However, I said, ‘I cannot because you have not yet married me. People will say, ‘why didn’t I
humble myself for the man to marry me before I got pregnant?’ I discussed it with him, and I
said I would abort the pregnancy. I went to the hospital and had the abortion there. I paid for it.
Ketika saya menyadari bahwa saya hamil, saya memberi tahu pria yang bersamaku. Dia
menyuruhku melahirkan. Namun, saya berkata, 'Saya tidak bisa karena kamu belum menikah
dengan saya. Orang-orang akan berkata, 'mengapa saya tidak merendahkan diri agar pria itu
menikahi saya sebelum saya hamil?' Saya mendiskusikannya dengannya, dan saya berkata saya
akan menggugurkan kehamilan. Saya pergi ke rumah sakit dan melakukan aborsi di sana. Saya
membayarnya.
Community Level
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The majority of participants described community level influences as perceived norms
and lay attitudes, sometimes positive but mostly negative, regarding the sociocultural acceptance
of adolescent sexual activity and its consequences (i.e., pregnancy, childbearing, abortion, STIs).
Mostly, young women faced significant pressure from their communities to be obedient and
behave “modestly” and “appropriately” for their age, as they were believed to be unprepared and
not developmentally, financially, socially, or emotionally ready to manage sex and its
consequences. Marriage was considered a prerequisite for sexual activity. For sexually active
at least allowed others to believe they had. A high school student from Kumasi discussed this:
dirasakan dan sikap awam, kadang-kadang positif tetapi kebanyakan negatif, mengenai
penerimaan sosiokultural dari aktivitas seksual remaja dan konsekuensinya (yaitu, kehamilan,
melahirkan anak, aborsi, IMS). Sebagian besar, perempuan muda menghadapi tekanan yang
signifikan dari komunitas mereka untuk patuh dan berperilaku “sederhana” dan “sesuai” untuk
usia mereka, karena mereka diyakini tidak siap dan tidak siap secara perkembangan, finansial,
sosial, atau emosional untuk mengatur seks dan konsekuensinya . Pernikahan dianggap sebagai
prasyarat untuk aktivitas seksual. Untuk remaja yang aktif secara seksual, kerahasiaan dan
membuat orang lain percaya bahwa mereka telah melakukannya. Seorang siswa sekolah menengah
At our age, I don’t think it (sex) is appropriate because they don’t consider us qualified for doing
such things in our community. We don’t want the people in the community to realize (that we are
having sex) because they may think we are not faithful. It’s not good to do when we are in
school.
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Pada usia kita, menurut saya (seks) tidak pantas karena mereka menganggap kita tidak memenuhi syarat untuk
melakukan hal-hal seperti itu di komunitas kita. Kami tidak ingin orang-orang di komunitas menyadari (bahwa
kami berhubungan seks) karena mereka mungkin mengira kami tidak setia. Itu tidak baik dilakukan saat kita di
sekolah.
Negative community norms did not always directly affect adolescents’ SRH decision-making
and behaviors in the intended ways. While elders, teachers, and religious and other community
leaders regularly counseled adolescents against sex, typically emphasizing its consequences and
moral repercussions, most participants balanced these negative sentiments with their own desire
for independence, autonomy, and “freedom,” as well as with outside influence from peers and
partners. Across interviews, some participants described the perceived rewards or positive
feelings that becoming sexually active could provide. A 17-year-old high school student from
Kumasi commented:
Norma negatif masyarakat tidak selalu secara langsung mempengaruhi pengambilan keputusan
dan perilaku SRH remaja dengan cara yang dimaksudkan. Sementara para penatua, guru, dan
pemimpin agama dan pemuka masyarakat lainnya secara teratur menasihati remaja tentang seks,
menyeimbangkan sentimen negatif ini dengan keinginan mereka sendiri untuk kemerdekaan,
otonomi, dan "kebebasan," serta dengan orang luar. pengaruh dari rekan dan mitra. Di seluruh
wawancara, beberapa peserta menggambarkan penghargaan yang dirasakan atau perasaan positif
yang dapat diberikan oleh menjadi aktif secara seksual. Seorang siswa sekolah menengah berusia
“It changes their attitudes because the moment they enter into sexual intercourse, they think
they’re on top of the world. They have reached a certain level where they cannot be controlled
anymore. They can do things on their own, behave anyhow, and do things at any time they like.
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For a few adolescents, childbearing and motherhood were viewed positively and believed to bring
responsibility, respect and an elevated social status, similar to older mothers in the community. A
“Ini mengubah sikap mereka karena saat mereka melakukan hubungan seksual, mereka mengira
mereka berada di puncak dunia. Mereka telah mencapai tingkat tertentu di mana mereka tidak
dapat dikendalikan lagi. Mereka dapat melakukan banyak hal sendiri, berperilaku apa pun, dan
melakukan sesuatu kapan saja mereka suka. Untuk beberapa remaja, melahirkan anak dan menjadi
ibu dipandang secara positif dan diyakini membawa tanggung jawab, rasa hormat, dan status
sosial yang lebih tinggi, serupa dengan ibu yang lebih tua di masyarakat. Seorang pasien klinik
Yes, my (community members) treatment has changed since they saw that now I’m also a
mother and matured, I can’t be dictated to. If I have pushed myself into teenage pregnancy and I
am also called ‘mother’ - ’mother’ as they are also called - they don’t scold me anymore.
service use were believed to be negative, unacceptable, and the behavior of “bad girls.” Stories
of “bad girls” were told by nearly all participants, as a 16-year-old Kumasi student described:
Ya, perlakuan saya (anggota komunitas) telah berubah sejak mereka melihat bahwa sekarang saya juga seorang
ibu dan dewasa, saya tidak dapat didikte. Jika saya memaksakan diri ke kehamilan remaja dan saya juga disebut
'ibu' - 'ibu' sebagaimana mereka juga dipanggil - mereka tidak akan memarahi saya lagi. Namun, sangat banyak,
seks, penggunaan kontrasepsi, kehamilan, melahirkan anak, aborsi, dan penggunaan layanan KB diyakini negatif,
tidak dapat diterima, dan perilaku "gadis nakal". Kisah "gadis nakal" diceritakan oleh hampir semua peserta,
Things will change because no one wants to walk with a bad girl. If you are pregnant at that age,
and you are walking with your pregnant friend, birds of the same feathers they say flock
19 16
together. People will then say you will be the next to get pregnant, so no one will want to walk
Segalanya akan berubah karena tidak ada yang mau berjalan dengan gadis nakal. Jika Anda hamil pada usia tersebut, dan Anda
berjalan dengan teman Anda yang sedang hamil, burung dengan bulu yang sama akan berkumpul bersama. Orang-orang kemudian
akan mengatakan Anda akan hamil berikutnya, jadi tidak ada yang mau berjalan bersamanya lagi.
Macro-social Level
At the macro-social level, most participants described structural and institutional factors
including education, health systems and religion, as influencing adolescent SRH decision-
engaging in sex and becoming pregnant and thus a “protective” factor. However, while high-
quality sex education was widely understood as necessary to promote positive SRH outcomes,
limited access to comprehensive and unbiased information perpetuated risky behaviors resulting
in negative outcomes, including unintended pregnancy, STI acquisition and less often maternal
mortality from unsafe abortion. While a few participants referenced supportive, trustworthy
teachers who were considered secure and reliable sources of information regarding safe sex,
contraception and FP services, the majority of participants described teachers as being a major
Pada tingkat makro-sosial, sebagian besar peserta menggambarkan faktor struktural dan
pengambilan keputusan dan perilaku SRH remaja. Secara umum, pencapaian pendidikan dianggap
sebagai prasyarat untuk melakukan hubungan seks dan hamil dan dengan demikian merupakan
faktor "pelindung". Namun, meskipun pendidikan seks berkualitas tinggi dipahami secara luas
sebagai hal yang diperlukan untuk mempromosikan hasil SRH yang positif, akses yang terbatas ke
informasi yang komprehensif dan tidak bias mengabadikan perilaku berisiko yang mengakibatkan
20 16
hasil negatif, termasuk kehamilan yang tidak diinginkan, penularan IMS dan lebih jarang kematian
ibu akibat aborsi yang tidak aman. Sementara beberapa peserta merujuk pada guru yang suportif
dan dapat dipercaya yang dianggap sebagai sumber informasi yang aman dan dapat diandalkan
mengenai seks aman, kontrasepsi dan layanan KB, sebagian besar peserta menggambarkan guru
sebagai sumber utama informasi yang bias, sikap menghakimi, diskriminasi, dan perlakuan buruk.
No one would like to ask teachers, but it depends on the relationship you have with them.
If you are close to the teacher, you can approach him/her. If it’s part of the syllabus, they will tell
you the truth, but I think they will say you are a bad girl if you ask them.
Tidak ada yang mau bertanya kepada guru, tetapi itu tergantung pada hubungan Anda dengan mereka.
Jika Anda dekat dengan guru, Anda bisa mendekatinya. Jika itu bagian dari silabus, mereka akan mengatakan
yang sebenarnya, tapi saya pikir mereka akan mengatakan Anda gadis nakal jika Anda bertanya kepada mereka
interviews, as young women described experiences seeking and receiving SRH and FP services
and interactions with facilities, providers, and specific types of care. A common theme was
concern about the availability and accessibility of quality SRH services – particularly those that
were adolescent friendly and confidential or that were financially and logistically feasible to
obtain. Moreover, some participants discussed prior experiences with and the resulting fear of
judgment and mistreatment from health care workers as a major barrier to health service
utilization. Stigma and discrimination from providers, especially nurses, prevented adolescents
from seeking SRH care, as they were frequently turned away. A 21-year-old Accra antenatal
clinic patient described her experience when she became pregnant: “One day, when I went to the
hospital, a nurse stared at me and said, ‘You are pregnant at this age, when we advise you, you
don’t listen.’ The nurses were not willing to take my card. I felt ashamed and vowed never to go
21 16
there again.”
Sistem kesehatan adalah pengaruh makro-sosial lain yang dibahas dalam sebagian besar
wawancara peserta, karena wanita muda menggambarkan pengalaman mencari dan menerima
layanan SRH dan KB serta interaksi dengan fasilitas, penyedia, dan jenis perawatan tertentu. Tema
umum adalah keprihatinan tentang ketersediaan dan aksesibilitas layanan SRH yang berkualitas -
terutama yang ramah remaja dan rahasia atau yang secara finansial dan logistik dapat diperoleh.
Selain itu, beberapa peserta mendiskusikan pengalaman sebelumnya dengan dan akibat ketakutan
akan penilaian dan perlakuan buruk dari petugas kesehatan sebagai penghalang utama
pemanfaatan layanan kesehatan. Stigma dan diskriminasi dari penyedia, terutama perawat,
menghalangi remaja untuk mencari perawatan SRH, karena mereka sering ditolak. Seorang pasien
klinik antenatal Accra berusia 21 tahun menggambarkan pengalamannya ketika dia hamil: “Suatu
hari, ketika saya pergi ke rumah sakit, seorang perawat menatap saya dan berkata, 'Kamu hamil
pada usia ini, ketika kami memberi tahu Anda, kamu tidak mendengarkan. 'Para perawat tidak
mau mengambil kartu saya. Saya merasa malu dan bersumpah untuk tidak pergi ke sana lagi. "
Most participants faced conflicting attitudes within the health care setting regarding
contraception and FP. In most cases, the need for or interest in contraceptive use was perceived
to be an admittance of premarital sex, and contraceptive use was considered acceptable only in
the context of marriage. Not all health systems encounters were negative though. With
considerable effort, diligence, and resources on part of the adolescent, unbiased, high-quality
and comprehensive sources of care could be found. Occasionally providers would welcome
adolescents into their clinics because they believed it was responsible to seek information,
especially before sexual initiation. A young student from Kumasi commented: “The health
worker will not treat her in a bad manner because she has come to know more about it (sexual
and reproductive health) before going to do those things (sex).” Similarly, a 16-year-old student
22 16
from Accra said: “(Health care workers) will see that a person wants to prevent unwanted
pregnancy, so they won't say anything (bad) because it is a good thing to keep from getting
pregnant.”
Sebagian besar peserta menghadapi sikap yang bertentangan dalam pengaturan perawatan
kesehatan tentang kontrasepsi dan KB. Dalam kebanyakan kasus, kebutuhan atau minat dalam
penggunaan kontrasepsi dianggap sebagai pengakuan terhadap hubungan seks pranikah, dan
penggunaan kontrasepsi dianggap hanya dapat diterima dalam konteks pernikahan. Tidak semua
pertemuan sistem kesehatan negatif. Dengan upaya yang cukup besar, ketekunan, dan sumber
daya dari pihak remaja, sumber perawatan yang tidak memihak, berkualitas tinggi dan
komprehensif dapat ditemukan. Kadang-kadang penyedia layanan akan menerima remaja di klinik
mereka karena mereka percaya itu bertanggung jawab untuk mencari informasi, terutama sebelum
memulai seksual. Seorang pelajar muda dari Kumasi berkomentar: “Petugas kesehatan tidak akan
memperlakukannya dengan cara yang buruk karena dia telah mengetahui lebih banyak tentang hal
itu (kesehatan seksual dan reproduksi) sebelum melakukan hal-hal itu (seks).” Demikian pula,
seorang siswa berusia 16 tahun dari Accra berkata: “(Petugas kesehatan) akan memastikan bahwa
seseorang ingin mencegah kehamilan yang tidak diinginkan, jadi mereka tidak akan mengatakan
apa-apa (buruk) karena itu adalah hal yang baik untuk tidak mendapatkan hamil."
Finally, religion was the most salient and perhaps most frequently described social
these women’s communities, emphasized the immorality of sex among young and unmarried
women. Most participants feared being shunned or rejected by their religious communities for
sex and its consequences. For some young women, particularly those still in school, this meant
remaining steadfast in their decisions be obedient, faithful, and abstinent. For sexually active
adolescents, guilt, shame, and worries about immoral behavior and ‘sin’ were a common
23 16
sentiment: “(Religious leaders) think sex is meant for adults…so people ‘paint black’ young
ones who involve themselves in those things, label them as bad girls.”
Religion was described by most participants as a primary cause of internal conflict between
moral values (theirs or their communities) and personal desires, actions, and needs. Some poor
young women struggled to reconcile religion with survival. A 22-year-old previously pregnant
Terakhir, agama adalah pengaruh sosial yang paling menonjol dan mungkin paling sering
dijelaskan pada SRH peserta. Ajaran agama, di semua denominasi yang diwakili dalam komunitas
wanita ini, menekankan amoralitas seks di antara wanita muda dan belum menikah. Sebagian
besar peserta takut dijauhi atau ditolak oleh komunitas agama mereka karena seks dan
konsekuensinya. Bagi beberapa remaja putri, terutama mereka yang masih bersekolah, ini berarti
tetap teguh dalam keputusan mereka menjadi patuh, setia, dan pantang. Bagi remaja yang aktif
secara seksual, rasa bersalah, malu, dan kekhawatiran tentang perilaku tidak bermoral dan 'dosa'
adalah sentimen umum: “(Para pemimpin agama) menganggap seks dimaksudkan untuk orang
dewasa… jadi orang 'mengecat' anak muda yang melibatkan diri dalam hal-hal itu, beri label
Agama dijelaskan oleh sebagian besar peserta sebagai penyebab utama konflik internal antara
nilai-nilai moral (mereka atau komunitas mereka) dan keinginan, tindakan, dan kebutuhan pribadi.
Beberapa wanita muda yang miskin berjuang untuk mendamaikan agama dengan kelangsungan
hidup. Seorang pasien klinik keluarga berencana berusia 22 tahun yang sebelumnya hamil
When they preach at church about it (premarital sex), it makes you feel that you should stop. But
when you come home to examine your condition, you will ask yourself what you will eat if you
24 16
stop.
Ketika mereka berkhotbah di gereja tentang hal itu (seks pranikah), itu membuat Anda merasa
bahwa Anda harus berhenti. Tetapi ketika Anda pulang untuk memeriksa kondisi Anda, Anda
akan bertanya pada diri sendiri apa yang akan Anda makan jika berhenti.
Discussion
comprehensively or collectively considered for their potential to shape a broad range of SRH
outcomes for young women, especially in Sub-Saharan Africa. In our study, consistent with a
social ecological framework, factors operating across interpersonal-, community-, and macro-
social levels had unique and interactive impacts on participants’ experiences with sexual activity,
pregnancy, abortion, childbirth, STIs, and contraception and use of FP services (Figure 1). The
hierarchical ecological structure, with each successive level (and factors within it) independently
influencing SRH decision-making and behaviors but also informing other levels. For instance,
community norms regarding the unacceptability of adolescent sex, founded in broader religious
violence, and adverse outcomes. This in turn contributed not only to unmet needs for SRH
information but perceptions that sex and contraceptive use are ‘bad girl’ behaviors. Moreover,
influences operating at each level sometimes conflicted with one another – participants in our
study struggled to balance and manage negative social forces with potentially positive ones, and
in many cases were forced to make critical health and life decisions without sufficient or
25 16
At the innermost level of influence, intimate partners were critical players in most participants’
SRH stories. Like other emerging research on partner violence, our work found that coercion was
a salient determinant of some participants’ experiences with unwanted sexual debut and activity,
contraceptive nonuse and discontinuation, pregnancy, and childbearing. These findings are
consistent with an increasing body of literature that has highlighted that imbalances in
and even verbal, psychological and physical abuse serve as barriers to FP and causes of
unintended pregnancy and its sequelae (Falb et al. 2014; Mboane and Bhatta 2015; Miller and
mechanisms of support and positive dynamics (which our study did not adequately address),
future interventions should at the very least involve a broader range of adolescents’ inner-circle
influences to encourage positive discourse about and social support for adolescent SRH.
At the outermost level, health systems factors, and specifically issues with access to and delivery
of FP care (e.g. cost, logistical barriers, capacity), have often been the emphasis of adolescent
SRH research in both developing and developed settings (Colarossi et al. 2014; Hokororo et al.
2014; Mathews et al. 2015). Our study builds upon this work to suggest that quality of care (or
lack thereof) and qualitative interactions within the health system are also important,
knowledge, and practices regarding adolescent sex, contraception, pregnancy, childbearing and
abortion, driven by larger negative community norms and religious ideologies, were prohibitive
for young Ghanaian women participating in this study who needed FP information and care. Fear
of judgment and mistreatment often prevented participants from seeking SRH services while
18 18
enacted stigma and discrimination perpetuated unmet care needs and subsequent poor outcomes.
A few other studies have demonstrated women’s experiences with and the adverse effects of
mistreatment in reproductive care settings, particularly antenatal and abortion services (Abedian
and Shahhosseini 2014; Bohren et al. 2015; Cook and Dickens 2014). Our study expands on this
work to focus on a broader set of SRH experiences and offers insight into the mechanism by
which health systems and providers form their practices around adolescent SRH. Health services
and policy efforts are urgently needed to identify effective strategies to improve adolescents’
access to and use of comprehensive, adolescent friendly, quality SRH health care (Hokororo et
al. 2014; Mathews et al 2015; Mchome et al. 2015). Such efforts are also needed to improve sex
education programs across the globe (Bailey et al., 2015; Ketting and Winkelmann 2013).
Finally, from a broad socio-cultural standpoint, our findings warrant attention, given the
stakeholders within each social ecological level (Schalet, 2011). The continued non-acceptance
of adolescent sexuality has been hypothesized to contribute to persistent higher rates of negative
outcomes like unintended pregnancies and STIs in settings with restrictive beliefs compared to
those like Northern Europe, with positive SRH paradigms (Cook and Dickens, 2014; Ketting and
Winkelmann, 2013). Moving forward, adolescent SRH research, programs, and policies can
harness health promotion strategies at each social level to reframe adolescent SRH and
restructure systems and institutions to accept adolescent SRH as an intrinsic component of health
and wellbeing and recognize its vulnerability to outside influences and its implications for health
19 18
Several limitations of our study are noteworthy. First, although our standard qualitative approach
used semi-structured interview guides, interviewers may have influenced the data collection and
analysis processes and contributed to bias. Second, participants in this study were not a
representative sample of all young women in Ghana or elsewhere and thus, results are not
generalizable to all populations and settings. Response and social desirability bias on part of
participants may have also been a concern, given the sensitive nature of our SRH study. Health
literacy was likely an issue, given our young and largely socially disadvantaged sample. To
address these potential biases, we rigorously trained and had regular debriefings with research
comprehension and clarity of questions, establishing rapport, and probing for sensitive
information. Nonetheless, these limitations likely affected our results, and thus findings should
be interpreted accordingly.
Conclusion
Overall, the diverse, multi-level, interactive social influences described here worked together to
shape the SRH experiences of our participants, often resulting in uninformed SRH decision-
making and precluding healthy FP behaviors. Our work can inform future theory-guided research
to better understand the specific pathways, including cognitive, behavioral, and even biological
mechanisms, through which complex social factors operate to independently and collectively
impact the full spectrum of SRH experiences during adolescence and young adulthood. The
findings have implications for multi-level research, program, and policy strategies to address the
social determinants of adolescent SRH. Public health efforts are needed to engage stakeholders at
all levels to shift paradigms and increase the acceptability of adolescent SRH to promote healthy
20 20
decision-making and behaviors and improve FP outcomes for young women worldwide.
Secara keseluruhan, pengaruh sosial yang beragam, multi-level, dan interaktif yang dijelaskan di sini bekerja
sama untuk membentuk pengalaman SRH peserta kami, yang sering kali mengakibatkan pengambilan keputusan
SRH yang tidak tepat dan menghalangi perilaku KB yang sehat. Pekerjaan kami dapat menginformasikan
penelitian yang dipandu teori di masa depan untuk lebih memahami jalur tertentu, termasuk mekanisme kognitif,
perilaku, dan bahkan biologis, yang melaluinya faktor sosial yang kompleks beroperasi untuk secara mandiri dan
kolektif memengaruhi spektrum penuh pengalaman SRH selama masa remaja dan dewasa muda. Temuan ini
berimplikasi pada penelitian multi-level, program, dan strategi kebijakan untuk mengatasi determinan sosial SRH
remaja. Upaya kesehatan masyarakat diperlukan untuk melibatkan pemangku kepentingan di semua tingkatan
untuk mengubah paradigma dan meningkatkan penerimaan SRH remaja untuk mempromosikan pengambilan
keputusan dan perilaku yang sehat serta meningkatkan hasil KB bagi wanita muda di seluruh dunia.
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Table 1. Sample Characteristics
(N=63) n %
Sociodemographics
Age in years
Mean: 17.871
Median: 18
Primary/None 7 11%
27 27
Employment status
Employed 13 20%
Unemployed 22 35%
Student 28 44%
Marital status
Married 7 11%
Preferred language
English 30 48%
Twi 31 49%
Religious affiliation
28 28
Catholic 3 5%
Muslim 7 11%
Protestant 13 21%
Pentecostal/Charismatics 34 54%
Other 4 7%
Recruitment site
29 29
Senior High school 16 26%
Reproductive History
0 28 44%
1 16 25%
2 12 19%
3 6 10%
15 1 2%
30 30
16 5 8%
17 5 8%
18 6 10%
19 1 2%
20 3 5%
21 4 6%
N/A 28 44%
0 12 19%
1 17 27%
2 4 6%
31 31
3 1 2%
N/A 28 44%
*Numbers may not add up to 100% given <5% missing responses for some sociodemographic
items.
32 32
Table 2. Main Identified Themes and Sub-Categories
Interpersonal
Peers
Partners
Parents
Macro-Social
Health Systems
Education
Religion
33 33
Figure 1. A Multi-Level Model of the Social Influences on Adolescent SRH Decision-
Making and Behavior
34 34