title: Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana.
abstract: Little is known about the multilevel 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.
authors.affiliation: a Department of Health Behavior and Health Education , University of Michigan School of Public Health , Ann Arbor , Michigan , USA.
authors.forename: Sneha
authors.initials: S
authors.lastname: Challa
authors.affiliation: b School of Public Health , University of Ghana , Legon , Ghana.
authors.forename: Abubakar
authors.initials: A
authors.lastname: Manu
authors.affiliation: c Department of Obstetrics and Gynecology , Komfo Anokye Teaching Hospital , Kumasi , Ghana.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Morhe
authors.affiliation: d Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , Michigan , USA.
authors.forename: Vanessa K
authors.initials: VK
authors.lastname: Dalton
authors.affiliation: a Department of Health Behavior and Health Education , University of Michigan School of Public Health , Ann Arbor , Michigan , USA.
authors.forename: Dana
authors.initials: D
authors.lastname: Loll
authors.affiliation: d Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , Michigan , USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Dozier
authors.affiliation: d Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , Michigan , USA.
authors.forename: Melissa K
authors.initials: MK
authors.lastname: Zochowski
authors.affiliation: c Department of Obstetrics and Gynecology , Komfo Anokye Teaching Hospital , Kumasi , Ghana.
authors.forename: Andrew
authors.initials: A
authors.lastname: Boakye
authors.affiliation: b School of Public Health , University of Ghana , Legon , Ghana.
authors.forename: Richard
authors.initials: R
authors.lastname: Adanu
authors.affiliation: d Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , Michigan , USA.
authors.forename: Kelli Stidham
authors.initials: KS
authors.lastname: Hall
mesh_terms: D000293:Adolescent; D003268:Contraception Behavior / Q000208:ethnology / Q000523:psychology; D003657:Decision Making; D005190:Family; D005193:Family Planning Services; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007398:Interpersonal Relations; D008297:Male; D010379:Peer Group; D036301:Qualitative Research; D060728:Reproductive Health / Q000208:ethnology; D012725:Sexual Behavior / Q000208:ethnology / Q000523:psychology; D000074384:Sexual Health; D064890:Social Determinants of Health; D055815:Young Adult
keywords: Adolescents; family planning; reproductive health; sexual health; social determinants of health; social ecological model