Multiple Levels of Social Influence On Adolescent Sexual and Reproductive Health Decision-Making and Behaviors in Ghana

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Women & Health

ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: http://www.tandfonline.com/loi/wwah20

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

To link to this article: http://dx.doi.org/10.1080/03630242.2017.1306607

Accepted author version posted online: 15


Mar 2017.

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http://www.tandfonline.com/action/journalInformation?journalCode=wwah20

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

Abubakar Manu, PhD

School of Public Health, University of Ghana, Legon, Ghana

Emmanuel Morhe, MD, FWACS, MPH

Komfo Anokye Teaching Hospital, Kumasi, Ghana

Vanessa K. Dalton, MD, MPH

University of Michigan, Ann Arbor, Michigan, USA

Dana Loll, MHS

University of Michigan, Ann Arbor, Michigan, USA

Jessica Dozier

University of Michigan, Ann Arbor, Michigan, USA

Melissa K. Zochowski, MBA

University of Michigan, Ann Arbor, Michigan, USA

Andrew Boakye, MPH

Komfo Anokye Teaching Hospital, Kumasi, Ghana

Richard Adanu MD

School of Public Health, University of Ghana, Legon, Ghana

Kelli Stidham Hall, PhD, MS

University of Michigan, Ann Arbor, Michigan, USA

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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

resolution. Community influences included perceived norms about acceptability/unacceptability

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;

social ecological model; adolescents

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Received 31 Aug 2016

Revised 25 Jan 2017

Accepted 28 Jan 2017

CONTACT Sneha Challa, MPH

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

healthy decision-making and behaviors can be particularly susceptible to outside influence

(UNICEF 2002). Factors at the individual-, interpersonal-, community- and systems-levels may

operate across adolescents’ social environments to contribute either positively or negatively to

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

well described, especially in the contexts of developing nations.

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

considerable availability of FP methods and services compared to other developing country

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

determinants of FP behaviors (e.g., women’s knowledge or attitudes), rather than on a diverse,

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

women in Sub-Saharan Africa and across the globe.

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-

making and behaviors.

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

serve (i.e., a range of women’s socio-demographic and reproductive background characteristics).

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,

religious background, and reproductive experiences.

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,

latar belakang agama, dan pengalaman reproduksi.

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

Michigan, and the Ghanaian Health Services.

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

partisipasi. Persetujuan protokol penelitian diperoleh dari Universitas Ghana, Universitas

Michigan, dan Layanan Kesehatan Ghana.

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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

elicited information on: 1) decision-making processes and circumstances surrounding sexual

initiation and/or pregnancy; 2) subsequent social, interpersonal, healthcare, and violence

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.

Sexually inexperienced or never-pregnant participants were asked about their perceptions of

community norms and the experiences of women in their communities (e.g., peers, social

6 6
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

kerangka ekologi sosial, disajikan di bawah ini.

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

10 10
women were vulnerable to criticism about their decisions or to unwelcome advice. A 15-year-old

student in Accra described this:

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

(sex) without using any family planning methods.

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

apa yang selalu dikhotbahkan oleh pendeta."

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

pregnant antenatal clinic patient from Accra said:

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

can take care of herself.

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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

difficulty at home and also pressure from peers.”

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

described a friend’s experience:

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

loves the guy, she gave in.

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

procreative gender norms around motherhood and childbearing as underpinnings of women’s

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

melanggengkan metode kontrasepsi yang tidak digunakan, disalahgunakan, atau dihentikan.

Meskipun tidak dikutip secara eksplisit (atau mungkin bahkan diakui) oleh peserta, beberapa

menceritakan kisah yang mengisyaratkan ketidakseimbangan dalam dinamika kekuasaan dan

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

antenatal hamil berusia 17 tahun mengatakan tentang pengalamannya sendiri:

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

adolescents, secret-keeping and nondisclosure allowed them to meet community expectations, or

at least allowed others to believe they had. A high school student from Kumasi discussed this:

Mayoritas peserta menggambarkan pengaruh tingkat komunitas sebagai norma yang

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

kerahasiaan memungkinkan mereka untuk memenuhi harapan komunitas, atau setidaknya

membuat orang lain percaya bahwa mereka telah melakukannya. Seorang siswa sekolah menengah

dari Kumasi membahas ini:

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.

17 16
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,

biasanya menekankan konsekuensi dan dampak moralnya, sebagian besar peserta

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

17 tahun dari Kumasi berkomentar:

“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

19-year-old family planning clinic patient stated of her own experience:

“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

keluarga berencana berusia 19 tahun menyatakan tentang pengalamannya sendiri:

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.

Overwhelmingly, however, sex, contraceptive use, pregnancy, childbearing, abortion and FP

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,

seperti yang dijelaskan oleh siswa Kumasi berusia 16 tahun:

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

with her again.

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-

making and behaviors. Generally, educational attainment was considered a prerequisite to

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

source of biased information, judgmental attitudes, discrimination, and mistreatment. A 16-year-

old Kumasi student said:

Pada tingkat makro-sosial, sebagian besar peserta menggambarkan faktor struktural dan

kelembagaan termasuk pendidikan, sistem kesehatan dan agama, yang mempengaruhi

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

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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.

Seorang siswa Kumasi berusia 16 tahun berkata:

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

Health systems were another macro-social influence discussed in most participants’

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

influence on participants’ SRH. Religious teachings, across all denominations represented in

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

family planning clinic patient described her own experience:

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

mereka sebagai gadis nakal. "

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

menceritakan pengalamannya sendiri:

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

To date, multiple levels of adolescents’ social environments have not been

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

social determinants of adolescent SRH described by our participants can be organized as a

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

sanctions, shaped participants’ interpersonal relationships, often resulting in secret-keeping,

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

consistent information, guidance, or support.

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

relationship decision-making power, reduced reproductive autonomy, contraceptive sabotage,

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

Silverman 2010). While additional research is needed to provide a more multidimensional

understanding of our participants’ interpersonal relationships and especially potential

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,

understudied determinants of adolescent SRH in Sub-Saharan Africa. Health provider attitudes,

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

overwhelming, persistent, and unsupportive positions on adolescent SRH taken by key

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

and wellbeing across the life course.

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

assistants and study investigators on appropriate interview procedures, including ensuring

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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26 26
Table 1. Sample Characteristics

(N=63) n %

Sociodemographics

Age in years

Mean: 17.871

Median: 18

Adolescents (15-19) 42 67%

Young Women (20-24) 20 32%

Highest level of education attained

Primary/None 7 11%

Middle/Junior High School 21 33%

Secondary/High School 28 44%

27 27
Employment status

Employed 13 20%

Unemployed 22 35%

Student 28 44%

Marital status

Married 7 11%

Not married 51 81%

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

Accra, Ghana 31 49%

Senior High School 12 20%

Antenatal/Postnatal Clinic 12 20%

Family Planning/Adolescent Clinic 7 9%

Kumasi, Ghana 32 51%

29 29
Senior High school 16 26%

Antenatal/Postnatal Clinic 10 16%

Family Planning/Adolescent Clinic 6 9%

Reproductive History

Number of prior pregnancies

0 28 44%

1 16 25%

2 12 19%

3 6 10%

Age at first pregnancy

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%

Number of live births

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

Levels of Influence Codes

Interpersonal

Peers

Partners

Parents

Community Perceived Norms

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

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