Background
The present generation of adolescents is the largest in history. Nearly 90 % live in low-and-middle-income countries where they constitute a far greater proportion of the total population because of the higher fertility rates as compared to high-income countries [
1,
2]. Most of these youngsters are sexually active [
3,
4], thus putting a significant number of the world population at risk for getting infected with sexually transmitted diseases or getting pregnant unintentionally.
Adolescent pregnancy is a recognized public health concern that has diverse consequences for the individual, the family, and society as a wholee [
5,
6]. Across sub-Saharan Africa, it is estimated that 14 million unintended pregnancies occur every year, with almost half occurring among women aged 15–24 years [
7]. In Ghana, the Reproductive and Child Health Department of the Ghana Health Services reported a rise in adolescent pregnancies among those aged 15 to 19 years from 43,465 in 2009 to 83,917 in 2013, representing 12.3 % of all pregnancies in the country [
8]. In rural areas like the Upper East Region, 21.7 % of adolescents aged 15 to 19 years had begun childbearing in 2014 as compared to 8.3 % in the Greater Accra region [
9].
Teen pregnancy contributes significantly to the high maternal mortality rate of 920 deaths per 100,000 live births in Africa [
6]. Among the 14.3 million adolescent girls that gave birth in 2008, one out of three was from sub-Saharan Africa and pregnancy-related morbidity and mortality rates are particularly high in this group [
10]. The bodies of adolescent girls are not yet sufficiently developed to deal with pregnancy in a healthy way, and this age group is twice as likely to die in childbirth as women aged 20 or over [
11]. Also, across Africa, one-quarter of the estimated 6 million unsafe abortions and 22,000 abortion-related deaths each year occur among women aged 15–19 years, showing that most of the pregnancies among teenagers are unwanted [
6].
While the use of effective contraception can prevent unwanted or unplanned pregnancies, few sexually active adolescents use contraceptives methods such as hormonal contraceptives (often referred to as ‘family planning’) and condoms. For example, among sexually active Ghanaian adolescents age 15 to 19 years, 80 % of girls and 63 % of boys were not using any contraceptive method at their last sexual encounters [
12]. An earlier report also showed that only 10 –12 % of adolescents’ aged 15 –19 years who were not using contraceptives intended to do so in the next 12 months [
13].
Addressing the high rate of teenage pregnancies and non-contraceptive use in Africa requires a context-specific understanding of why teen pregnancy is so high among adolescents while a significant group does seem to manage to prevent getting pregnant. Previously identified barriers to contraceptive use among adolescents in sub-Saharan Africa include inadequate sexual knowledge and risk perceptions, lack of skills to negotiate safer sex options, ambivalent attitudes towards sex, lack of access to educational and health services, and negative social norms around premarital sexual activity and pregnancy [Krugu, Mevissen, Meret & Ruiter, under review, [
14,
15]]. Other empirical reports also indicate that young girls may engage in unsafe sex because they have not considered contraception [[
16], Krugu et al., under review], are afraid of possible side effects [
17], are more worried about the safety of contraceptives than preventing an unintended pregnancy [
18], or are not adequately informed about the risk of pregnancy or disease posed by unsafe sex [
19].
However, most of these studies have focused on pregnant girls and those with pregnancy experience – following the general long held practice of merely focusing on people with the health problems. There is limited work on never-pregnant adolescent girls’ perceptions regarding pregnancy prevention. Gaining an understanding of adolescent pregnancy from the perspective of never-pregnant teenage girls can play a major role in identifying factors that influence sexual decision-making in young women regarding initiating sexual activity and preventing pregnancy. Studying girls without pregnancy experience could also provide pointers on the capacity and needs that girls with pregnancy experience are lacking, which, in turn, facilitates the development of intervention goals. Knowledge of the perceptions, beliefs and behaviors of never-been-pregnant adolescent girls is, therefore, necessary to guide the content of future teenage pregnancy prevention programs.
To fill this gap, we conducted the present study as part of a larger research project exploring the behavioral, environmental and psychosocial factors influencing adolescent sexual and reproductive health behaviors. More specifically, the project was initiated to create a comprehensive picture of factors associated with the high teenage pregnancy rates in Northern Ghana and to inform future prevention strategies. After a study focusing on teenage girls with pregnancy experience in Bolgatanga, Ghana (Krugu et al., under review), the current study reports on the qualitative interviews conducted among adolescent girls without pregnancy experience. The aim was to explore the psychosocial and environmental factors influencing their sexual decision-making, which seems to put them not or less at risk of unintended pregnancies as compared to their peers with pregnancy experience.
Methods
Study design
The study used semi-structured individual in-depth interviews to explore the behavioral, environmental and psychosocial determinants of sexual choices of adolescent girls who do not have pregnancy experience. The semi-structuring helped to ensure consistency across interviewers and interviewees. The Ethics Committee of the Ghana Health Services in Accra and the Ethics Review Board of Maastricht University in the Netherlands approved the study.
Study setting
We conducted the study in the Bolgatanga Municipality in northern Ghana. Bolgatanga is located 743.83 km to the north of Accra (capital of Ghana) and covering a total land area of 729 sq km
2. Females make up 52.3 % of an estimated population of 131,550 and 44 % are below 18 years with a growth rate of 3.0 % [
20]. Agriculture is the main economic activity in the Bolgatanga Municipality, and it is among the poorest districts in the country with 35 % of its population living on less than the World Bank’s threshold of $1.25 per day [
21]. The healthcare system in the Municipality includes a Regional Hospital, nine Health Centres, and several Community-based Health Planning and Services (CHPS) compounds.
Study population
Our final sample included 20 adolescent girls between the ages of 14 and 19 years (M = 17.3, SD = 1.59) with no pregnancy experience and living in the Bolgatanga Municipality of the Upper East region of Ghana. Six participants reported sex experience; 3 of them were 18 years of age and the other 3, 19 years. The girls came from families engaged in peasant farming or doing petty trading businesses. The girls lived together with siblings in larger families – an average of 5 children per family. Two girls had lost their fathers, and one had lost her mother. One girl came from a polygamous family, and another one had a Burkinabe father and a Ghanaian mother. All the participants were still in various stages of high school. The sample included 5 Muslims and 15 Christians, and all of them indicated that religion was important to them. Although all the girls were from the low socio-economic background, they all had clear goals and hopes of a better future career and indicated their preparedness to work towards such goals.
Recruitment and Procedures
The study used a purposeful homogeneous sampling technique to recruit the participants [
22]. A short description of the study, including the purpose, the voluntary nature of participation and how to register to participate, was advertised in schools and other public places in Bolgatanga where young girls are likely to visit. Also, research assistants visited schools to recruit girls. Interested participants confirmed their participation by completing an informed consent form and those below the age of 18 years took the form home for parental consent before they could participate. Participants were enrolled day-by-day until thematic saturation was reached.
In all, 28 girls signed up for the study, of which 25 met the criteria of being adolescent (10 ≤ years old ≤ 19) and having no pregnancy experience. The 25 girls were then asked to complete informed consent forms and for those below age 18 years (N = 8), research assistants visited their homes to explain the study and secured additional parental consent. In the end, we interviewed 23 girls who returned completed forms to participate. We did not compensate for participation, but where necessary, participants’ transport costs were paid, and all received a soda drink at the beginning of each interview. The interviews lasted between 45 minutes and 1 hour. All interviews were audiotape recorded, and after transcription, the tapes were erased.
Researching sensitive issues such as sexuality in a culturally inhibiting environment like northern Ghana necessitated an ethical awareness in the development of the research method. Anonymity and voluntary participation was warranted by not documenting identifiable details of participants and not applying any persuasion regarding participation. Also, the research team, was conscious of concerns that young girls in northern Ghana are in a position of both economic and social vulnerability [
23]. To ensure that hierarchical research methods did not exploit the girls, the research assistants were trained to pose questions as supportive as possible and the interviews terminated if signs of distress were observed. At the beginning of each interview, participants were also assured of the confidential handling of the data to avoid that they provide socially acceptable responses. Finally, participants were informed of the option to quit the interview at any time necessary without having to provide an explanation.
Since the participants were all high school students who could speak and understand English, the interviews were mostly carried out in English; both the questions posed by the interviewer as well as the responses given by the participants. However, sometimes the research assistant (who spoke English but also was a native speaker of ‘Frafra’) had to translate questions posed in English by the lead interviewer for participants who could not understand some of the English formulations or questions. Also, sometimes participant’s responses were in Frafra if they had difficulties finding the correct English expression. These responses were also translated in the same manner to the lead interviewer, and we recorded both languages for the transcription. The first author, who speaks the local language as well, validated the transcriptions by listening to the voice recordings and made minor corrections where necessary. The participants determined the locations of the interviews. Out of the 23 individual interviews conducted, 3 were excluded from the analysis because of bad recording quality and/or interview stopping half-way because participants had to attend to parental calls.
Research instrument
We used a semi-structured interview guide that was developed based on theoretical concepts and literature review. The interview protocol included themes related to knowledge, attitude, self-efficacy, risk perception, and social norms addressing topics such as relationships, sex experience, pregnancy, contraception, and sexuality communication. Table
1 presents the main themes and topics of the interview instrument. Two young trained women, a Ghanaian with prior training in youth peer sex education and a Dutch graduate student from Maastricht University, conducted and transcribed the interviews. The corresponding author validated the transcripts by listening to the interviews and making minor corrections where necessary.
Table 1
Interview protocol showing the themes and topics that guided the data collection
Introduction | Age, background, school/work, family, life, religion, ethnic group. | Can you tell me something about yourself? What does your life look like? Do you go to school, work? What do you like to do in your free time? Can you tell me a bit about your family? Would you consider yourself being religious? What role does religion play in your life? |
Background variables |
Demographics |
Pregnancy/motherhood | Pregnancy | How do you think about pregnancy? What do you think it would be like to be a mother? What would be a good time to become pregnant/a mother according to you? How would you feel if you found out you were pregnant now/at this moment in your life? What would you do if you figured out you were pregnant now. Do you know anyone of your age who got pregnant? What do you think of that? How do important others in your surrounding think about teenage pregnancy in general of ‘if it was you being pregnant’ How do you feel about their opinion? |
Motherhood |
Important others include: mother, father, brother/sister, friends, boys/girls in your village or at your school, the teachers, and church leaders? Health centre workers? |
Femininity/masculinity | | What does it mean to be a woman? What do you think are the main differences between men and women of your age? How do important others think about women? |
Relationships | Current relationships | Are you in a relationship at the moment? How did your relationship start? How would you define your current relationship? Where do you meet your partner? |
Past relationships |
First relationship |
What do important others think about your relationship? |
Sex experience | Attitude towards sex | Did you ever have sex? Why/why not? How many partners? |
Positive/negative experiences | If you have sex, where (At home? Church? Bushes? Parties? School?) |
How would you describe your sex life/how are your sex experiences? (positive/negative experiences) |
Do other people know you have sex? (why/why not). What do you think important others think about you having sex? |
Safe sex | Definition and importance of sex | What do you consider safe sex? |
Definition of safe sex | Do you use condoms? (how often?) |
Contraceptive use | Do you use other types of contraception? Which one? What are reasons for using/not using condoms (or other forms of contraception)? Who do you think is responsible for contraception? What are advantages and disadvantages of condoms/contraception? What do you prefer (condom or other contraceptives) and why? Should men/women carry them around? |
Condom use |
Where/how do they get condoms/other contraception |
Safe sex negotiation with partner | | People don’t always want the same with sex. For example some want to use condom others don’t. Or some like sex in one way and others like it in different way. What do you do/would you do if partner want something else? What if you want to use a condom but he doesn’t? |
Have you ever persuaded a man to practice safe sex? Can you describe how you discussed it with him? What was the reason for not discussing? |
Communication about (safe) sex with partner | Topics of communication with partner | Which topics can/can’t you discuss with partner? |
Taboo topics | Do you ever talk about sex with your friends/sisters/parents? |
Communication | |
Sex education/sex communication | Information sources | Did you learn about sex? How/by whom? Did you have sex education at school? What did you think of it? Do you ever talk about sex, contraceptives, motherhood at school, with your friends, family? Do you think you know all you need to know about sex/safe sex? If you have questions (e.g. on condom/contraception/pregnancy) where would you go? Did you have to go to health clinic for sex-related issues? What is your experience? |
Data analysis
After validity checks and proof-reading, the 20 transcripts in MS Word documents were exported into NVivo 10.0 qualitative software for analysis. The analysis took the form of thematic exposition -- identifying the dilemmas, fears, and beliefs within the narratives [
24]. A thematic exposition allows the researcher to determine categories and construct concepts using a grounded theory approach [
25]. The analysis employed a three-level coding system. At the first level, the transcripts were repeatedly read to identify phrases which could be coded into general themes. We grouped these initial codes into smaller themes at the second level coding (axial coding or pattern coding). At the third or selective coding level, we reviewed level one and two codes to confirm the various thematic categories. The second author checked the three levels of codes [
26] against the original transcripts and discussed a few little parts that were not covered under the right topics back-and-forth with the first author to reach an agreement. The thematic categories were then summarized and used as the basis of subordinate and secondary analysis of the determinants of adolescent girls’ sexual health decision-making processes in the Bolgatanga area as viewed from the perspective of unmarried teenagers without pregnancy experienced.
Discussion
Knowledge of what makes girls without pregnancy experience differ from girls with (unintended) pregnancy experience can greatly enhance the development of effective pregnancy prevention programs. In this study, we interviewed adolescent girls living in communities with high teenage pregnancy rates but without pregnancy experiences themselves. The results suggest that the girls had a cordial and positive relationship with their parents and did talk about sexuality with their mothers and friends. Although much of the mother-daughter communication was largely limited to moral advice to abstain from sexual relationships, some girls received more extensive advice, including safer sex practices to avoid unwanted pregnancy. In school, the majority of the girls seemed to have received sex education with the inclusion of condom use. The girls also reported high awareness of the risk of pregnancy through unprotected sexual intercourse. They were also positive about carrying condoms (some girls) and using condoms. All the girls also indicated strong self-efficacy beliefs towards negotiating condom use. On the other hand, the girls believed that it is the boys’ responsibility to buy condoms, and they had negative attitudes towards so-called family planning (contraceptives other than condoms). There were some overlaps in the narratives of the girls. However, conclusions cannot be made base on these overlapping reporting of only 20 qualitative interviews. Whether there are potential relationships between the reports of the girls among the emerged themes will require a quantitative survey involving a statistically significant sample.
The results also suggest that the girls had clear future goals regarding educational levels and careers they want to achieve, combined with clear plans on how to achieve them. The latter mostly focused on preventing any pregnancy before having finished education and before having a proper job by staying away from boys or refusing any sex without condoms. All the girls had clear intentions for future condom use and those who were sexually active reported consistently using condoms to avoid pregnancy until the achievement of their plans.
Our participants’ experiences of frequently receiving advice on sex and relationship issues from their mothers are contrary to what was reported by Krugu et al. (under review), where the pregnancy experienced girls had no form of sex communication at home. Parents who keep the communication lines open all the time have been reported to have a closer and more connected relationship with their children, which allows them also to discuss sexuality topics [
27,
28]. Although some of our participants’ experiences were largely that of being dissuaded from having sex, those who received more extensive advice, including condom use discussions, reported being happy to know how to “have sex with a man”. Which might explain why they could avoid unwanted pregnancy as compared to the pregnancy experienced girls of Krugu et al. (under review). Past research suggests that mother–adolescent discussion about condoms before adolescent’s sexual initiation was associated with more use of condoms at sexual initiation and could set the stage for later consistent condom use [
29]. However, factors such as lack of time, lack of knowledge, not being comfortable and perceiving that their daughters are not at risk of pregnancy or STIs have been reported to inhibit mother-daughter communication on safe sex practices [
28,
30]. Further exploration into the influences of mother-daughter sex communication is necessary to support family based interventions to address teenage pregnancy in North Ghana.
In contrast, to the girls with pregnancy experience (Krugu et al., under review) the girls in the current study all reported having had some form of school-based sex education that included lessons on the use of condoms. Across Africa, formal school-based sex education programs focus on promoting abstinence-only messages [
31]. However, comprehensive programs also provide information on birth control methods and condoms to prevent both pregnancy and STIs [
32]. These different topics included in sex education across schools could explain the differences in safer sex choices made by the girls without pregnancy experience as compared to the girls with pregnancy experience. Systematic reviews suggest that the effects of abstinence-only programs in reducing sexual risk behaviors have been minimal [
33‐
35]. Rather, adolescents who received comprehensive sex education had a lower risk of pregnancy than those who received abstinence-only or no sex education [
36].
The girls in this study reported positive attitudes towards condom use, exhibited high condom use self-efficacy, high-risk perceptions towards pregnancy, and had clear intentions towards condom use as compared to the girls who became pregnant against their wish (Krugu et al., under review). Some studies across Africa have demonstrated the role of attitude, self-efficacy beliefs, risk perception and subjective norm in shaping young people’s intention to use condoms [
37‐
39]. Future research that seeks to confirm the relevance of these personal determinants in condom use decision-making among the adolescent population in northern Ghana is necessary to guide intervention development.
The girls in this study mentioned specific plans such as using condoms to prevent unwanted pregnancies that may threaten future goals. This is in contrast to Krugu et al.’s (under review) study of girls with pregnancy experience. The girls with pregnancy experience often described and perceived themselves as being subordinate to boys. They also seemed not to have specific future goals. The current finding adds a potential new dimension to the efforts to prevent teenage pregnancy in Ghana. Several studies have shown the positive effects on health behavior and decision making of having clear future goals or purpose for living [
40‐
43]. Our finding suggests that the proactive pregnancy preventive behaviors of adolescent girls to fulfill their aims could influence whether or not they will become victims of unintended pregnancy. Thus, it could be useful to get young girls to relate safe sex with life goals that they can forfeit by the outcomes of unsafe sexual activities [
44]. At the same time, however, within the African context, goal-setting as a strategy to increase health-related decision making of girls may be difficult to accomplish. Across rural Africa, the choices of young women are often constrained by their narrow range of experiences, and they frequently project for themselves a life similar to that of their mothers, which is often characterized by low income, and limited economic opportunities [
45].
A concerning finding is that, similar to the girls with pregnancy experience (Krugu et al., under review), the girls in the current study also had strong negative attitudes towards family planning (i.e. using other methods of contraception besides condoms) and believed that boys are responsible for buying and carrying condoms. These beliefs mostly put boys in control of safer sex choices. Therefore, although the girls in this study reported clear intentions to use condoms, they may, in the end, fail to act by their intentions. Programs aimed at promoting condom use need to stress that the importance of being prepared and in control or having condoms available is also important for girls. In addition, the ‘double Dutch’ approach (using another contraceptive method in addition to condoms) has been shown to be safer for pregnancy prevention than only relying on condom use [
46]. Future research should explore strategies to change girls’ negative beliefs about using family planning outside marriage context.
Study Limitations
Since all the girls belong to the ‘frafra’ ethnic group living in Bolgatanga, the findings are not necessarily generalizable to other African populations. However, the findings offer interesting perspectives to the discourse on adolescent girls’ sexual behaviors in Ghana and should be further confirmed through quantitative methods. Also, fearing that age difference between interviewers and participants may inhibit open discussion on sexuality, we used young women to collect the data. The interviewers had limited experience in conducting in-depth interviews on sensitive topics like sexuality. They might have had difficulty in determining whether or not a participant was responding in a socially desirable manner. More experienced interviewers could have enriched the data through the right follow-up questions or further probing. Also, the context in which we conducted the interviews could have influenced the results. A few times, interview sessions had to be moved to a more quiet location in the course of interviewing and the disruption led to some questions remaining unanswered. Our recruitment procedure required participants less than 18 years of age to obtain parental consent. It is possible that only parents who accepted that their daughter’s can discuss sexual topics openly consented, thus causing a bias in the generalizability of our sample. The recruitment procedure also ended up with only school-going girls as participants as well as with a sample of which only a limited number had sexual experiences. Both could have influenced our findings. Since the school setting can define the sexual socialization of girls in different ways [
47], it is possible that the results would have differed if out of school girls were included in the sample. For girls without sexual experience, the answers on how they would deal with actual sex-related situations are therefore hypothetical.
Conclusion
This study suggests that a more positive mother-daughter communication at home may be one of the protective factors in the sexual decision-making processes of girls. Since previous research also showed that mothers seem to be important socializing agents in adolescent sexual decision-making [
27,
48], interventions may focus on helping the maternal parent become skilled, comfortable and open in discussions about sexuality with their daughters. Also, it seemed that access to school-based sex education that includes condom use information made a difference between the girls with pregnancy experience and those reported in this study. Therefore, the parental contribution could also include engaging in school policy development to ensure that school-based sexuality education goes beyond abstinence-only messages to equip adolescents for safer sexual choices.
Our results also point out how the attitude towards contraception, risk perception towards pregnancy, and girls condom use self-efficacy can influence the performance of action specific sub-behaviors necessary for girls’ safer sex practices. Preparatory sub-behaviors such as buying and carrying contraceptives and skills to communicate contraceptive use wishes are vital to enable girls to make safer sex choices [
49]. Future intervention planners should first examine which cognitive beliefs are more important in addressing specific preparatory behaviors related to condom use. Such efforts may consider the ‘double-dutch’ approach of promoting the combined use of both condoms and hormonal contraceptives to enable girls to take full control of their sexuality [
46].
Finally, this study suggests that girls with higher purpose may tend to use more pregnancy preventive measures to avoid unintended pregnancy and stay focused on achieving their life goals. Intervention studies designed to improve goal-setting and experiences of purpose in life may be warranted. Doing so could offer new avenues for girls’ increased use of pregnancy preventive measures, thereby decreasing the chances that they will become pregnant against their wish.
Competing interests
The first author is the director of YHFG, and the current study is part of his Ph, D. project at Maastricht University. All other authors declare that they have no competing interests.
Authors’ contributions
JKK, FEFM, and RACR conceived the study, JKK and FEFM contributed to the design, PA and JKK collected the data, JKK, PA and FEFM contributed to the data analysis. JKK drafted the manuscript. All authors read, reviewed and approved the final draft.